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THE 



rt^ESTERN JOURNAL 



MEDICINE AND SURGERY: 

ZDITED BT 

DANIEL DRAKE, M.D., 

AND 

LUNSFORD P. YANDELL, M.D., 

M0PES30RS IN THE LOtTISVILLE MEDICAL INSTITUTE, 
AlfD 

THOMAS W. COLESCOTT, M.D. 



VOL. VII. 



LOUISVILLE, KY. 
PUBLISHED MONTHLY BY PRENTICE & WEISSINGER, 

PBOPRIKTORS AND PRINTERS. 
1843. 



THE 



WESTERN JOURNAL 



0 F 



MEDICINE AND SURGERY. 



JANUARY, 1 843. 



Art. I. — An Experimental and Critical Inquinj into the 
Nature and Treatment of Wounds of the Intestines. By 
Samuel D. Gross, M. D., Professor of Surgery in the Lou- 
isville Medical Institute. 

A monograph on wounds of the intestines has been an acknowl- 
edged desideratum with the profession. The work of Mr. Travers, 
the only production of the kind in the English language, has been 
out of print nearly a quarter of a century, and hence the only infor- 
mation accessible to practitioners, especially those of the United 
States, is such as is to be found in the various periodicals of the day, 
or in our systematic treatises on surgery. The latter, unfortunately, 
contain little, if any thing, that is worthy of reliance; they enter into no 
details, and some of them do not even allude to the subject; a circum- 
stancesomuch the more surprisingwhenwe reflect upon the importance 
of these injuries, and the attention which has been bestowed upon them 
by some of the most respectable members of the profession. In the 
present undertaking an attempt has been made to supply this defi- 
ciency, by exhibiting a connected view of the subject, embracing an 
I 



2 



Gross on Wounds of the Intestines. 



account of the results of my own researches, and of those who have 
preceded me in the same field of inquiry. 

My investigations were commenced in the spring of 1811, and 
continued, with various intermissions, until a few months ago. The 
object was, in the first place, to inquire into the process employed by 
nature in repairing wounds of the intestinal tube; and secondly, and 
more particularly, to determine, if possible, the value of the various 
methods of treatment that have been recommended from the time of 
Ramdohr down to the present day. The experiments, upwards of 
seventy in number, were performed exclusively on the dog, as the 
most eligible animal that could be procured for the purpose, with 
the assistance of my private pupils, Messrs. Wendel, Comstock, Ba- 
ker, Shumard, Church, Grant and Williams. Many of them were 
also witnessed by Mr., now Dr. Hagan, by Dr. Colescott, one of the 
Editors of the Western Journal of Medicine and Surgery, by Mr. 
Mullen, and by Dr. Richard Ferguson, of this city. To the latter 
gentleman, who has kindly furnished most of the accompanying 
drawings, 1 am desirous thus publicly to tender my acknowledgments. 

It is proper to state that an abstract of this essay was read before 
the Medical Convention of Ohio, at its last meeting at Cincinnati, in 
May 1842. 

The notions of the older writers respecting the nature and 
treatment of wounds of the intestines were, for the most part, 
exceedingly crude and erroneous. Neglecting to institute 
experiments for their successful elucidation, they contented 
themselves with such facts as they witnessed in the human 
subject; and as these were not only few, but generally imper- 
fectly noted, the conclusions which they deduced from them 
were far from throwing any real and substantial light upon 
this interesting branch of pathology. Indeed, until the pub- 
lication of the researches of Mr. Travers, of London, early in 
the present century, the management of wounds and injuries 
of the alimentary tube was altogether empirical, being regu- 
lated rather by accident than sound principles derived from 
the study of healthy and morbid action. His labors in this 
department, conducted as they were at an early period of his 
professional life, evinced no ordinary judgment and talent, 
and served as a happy presage of the reputation which has 
since awaited him. They are comprised in an octavo vol- 
ume of nearly four hundred pages, including a complete sum- 
mary of aU that was known on the subject at the time at 



Gross on Wounds of the Intestines. 



3 



which it appeared in 1812. It is entitled: "An Inquiry into 
the Process of Nature in Repairing Injuries of the Intes- 
tines; Illustrating the Treatment of Penetrating wounds and 
Strangulated Hernia;" and is one of the most able and phi- 
losophical productions that have enriched the science of sur- 
gery within the last fifty years, so prolific in discovery and 
improvement. 

In the investigations just referred to, Mr. Travers did not, 
like his predecessors, limit his inquiries to the hmnan sub- 
ject, but extended them to the inferior animals, upon 
which, especially the dog, he performed a series of the most 
interesting experiments, equal in point of beauty and im- 
portance to those instituted by his countryman. Dr. Jones, 
to ascertain the process employed by nature in suppressing 
hemorrhage from divided arteries. The results of tliese 
researches are well-known to the profession, and any further 
notice of them, excepting in an incidental manner, will there- 
fore be unnecessary in a work of this kind, which is intend- 
ed more particularly as a record of my own observations and 
of the facts that have been disclosed within the last quarter 
of a century. It is but just to say that several years before 
Mr. Travers issued his work. Dr. Thomas Smith, of the 
Island of St. Croix, was engaged in making some researches 
on the same subject, an account of which was published in 
his Inaugural Dissertation, presented to the Trustees and 
Faculty of the University of Pennsylvania, in 1&05. His 
object seems to have been rather to inquire into the pro- 
priety of using certain kinds of sutures, recommended by Le 
Dran, Ramdohr, John Bell, and other surgeons, than to as- 
certain the process employed by nature in effecting repara- 
tion. His experiments, twelve in number, were conducted 
with considerable care, though he has failed, in almost every 
instance, to notice with proper minuteness the results of his 
dissections; a circumstance so much the less surprising when 
we reflect upon the low state of pathological science at the 
period at which he wrote. Limited as these researches arc, and 
imperfectly as they have been detailed by their author, they 



4 



Gross on Wounds of the Intestines. 



nevertheless tended to establish some important practical pre- 
cepts, to which allusion will be made in another part of this 
inquiry. 

Before I proceed to detail the results of my own experi- 
ments, and the inferences which I have been led to deduce 
from them, it will not be amiss to make some remarks on the 
structure of the alimentary tube, the arrangement of the peri- 
toneal cavity, and the phenomena which characterize the pre- 
sence of wounds in the situation in question. 

I. — Structure of the Alimentary Canal. 

Into the consideration of the structure of the intestinal canal 
I do not deem it necessary to enter at any length, as it must 
be familiar to all who have any pretensions to correct ana- 
tomical knowledge. It will be sufficient for the object I have 
in view to make a few remarks respecting the different tunics, 
and the manner in which they are united to each other. 

The outer membrane of the intestinal tube belongs to the 
class of serous textures, and deserves to be mentioned here 
chiefly on account of the facility with which it takes on in- 
flammation, and the important part it plays in the reparation 
of traumatic lesions. It is intimately connected, except along 
the line of reflection of the mesentery and omentum, to the 
subjacent muscular tunic, by short, dense cellular sub- 
stance, and consists every where of a single lamella, the 
strength of which varies in proportion to the age of the indi- 
vidual. In young animals it is easily lacerated, and incapa- 
ble of withstanding much traction or pressure. Hence, if, in 
sewing up a wounded bowel, tlie ligature be carried merely 
through the serous investment, it will be almost certain to be 
torn out in the efforts which are necessary to replace the part 
within the abdomen. When inflamed, this tunic promptly 
pours out plastic lymph, which, under favorable circumstan- 
ces, becomes readily organized. If the morbid action runs 
high, the lymph is generally intermixed with serum, and some- 
times oven with blood. Pus is a more common attendant on 



Gross on Wounds of the Intestines. 5 

the chronic form of the disease; it is, hou-ever, occasionally 
observed in the acute stage, and that, too, within a very short 
time after the development of the disorder. 

The muscular tunic, interposed between the preceding and 
the cellulo-fibrous, to both of which it is intimately connect- 
ed, is composed of two planes of fibres, a superficial and 
deep-seated. The first, which is much the more delicate of 
the two, is made up of thin, pale fibres, which are arranged 
longitudinally, and which exhibit certain, but as far as the 
present inquiry is concerned, unimportant peculiarities in dif- 
ferent parts of the tube. The second layer consists of circu- 
lar fibres, much more distinctly marked than the preceding, 
which extend in parallel lines round the entire circumference 
of the bowel, their extremities being inserted as it were into 
each other. 

Lying beneath this muscular plane is the celebrated 7ier- 
vous tunic, as it was called by the ancient writers. Alter- 
nately admitted by some and rejected by others, this layer has 
been recently described by 3Ions. Cruveilhier,* under the 
name of the fibrous lamella, in consideration of its stnicture, 
which closely assimilates itself to that class of tissues. It is in- 
timately connected, on the one hand, with the mucous mem- 
brane, and, on the other, with the muscular tunic, into the 
latter of which it sends a large number of processes, of a 
dense, firm character, which thus tend to strengthen the union 
between them. In its thickness and consistence it varies in 
difterent portions of the canal, being at its minimum in the ileum 
and colon, and at its maximum in the remainder of the small 
and large bowels. Strong and resisting, it is semi-transpar- 
ent, devoid of elasticity, and composed of condensed cellular 
tissue, in which it is impossible to distinguish any of that 
linear disposition so conspicuous in the fibrous membranes, 
properly so called. The filaments of which it consists inter- 
lace with each other in every conceivable manner, forming 
thus a very close net-work, which it is difficult to unravel by 



♦Anatomie Descriptive, T. ii, p. 470. 
1 * 



6 



Gross 011 Wounds of the Intestines. 



insufflation and other artificial processes. In great obesity 
small particles of fat are occasionally to be seen in its meshes, 
which always disappear in emaciation, however induced. In 
chronic affections, especially in such as are of a malignant 
nature, this tunic is often remarkably altered in its structure, 
being rendered much thicker than in the normal state, at the 
same time that it assumes a dense and almost gristly hard- 
ness. It readily re-unites when divided, as I have witnessed 
in numerous experiments, and deserves to be attentively stu- 
died, as it is the membrane through which the surgeon 
should always carry his needle in sewing up wounds of the 
intestines. 

This tunic — for so indeed it should be considered — is much 
more distinct in carnivorous animals than in herbivorous, or 
than in the human subject. In the small bowel of the Afri- 
can lion it is an exceedingly firm, dense, and elastic texture, 
of a white opake aspect, capable of great resistance, and 
nearly half a line in thickness. In the bear its characters are 
nearly similar. In the dog it is less strong, and also less dis- 
tinctly fibrous, yet more so, considerably, than in the human 
subject. In the horse it forms a thick inelastic layer, of a 
dull greyish color, which frequently contains a good deal of 
adeps. In the ox its properties are very much of the same 
nature. 

The internal vicmhrane, of a mucous character, varies in 
thickness and consistence, as well as in the mode of its arrange- 
ment, in different parts of the tube, and does not require 
any particular notice in relation to the subject under conside- 
ration. It is sufficient to observe that it is highly vascular 
and sensitive; that it re-unites with great difficulty, compara- 
tively speaking, when divided; and that, although extremely 
prone to inflammation, it rarely, when thus affected, deposits 
plastic lymph, the constant and invariable product of perito- 
nitis. 



Gross on Wounds of the Intestines. 



II. — Nature and Extent of the Peritoneal Cavitij. 

Is there any cavity, properly so called, in the peritoneal 
sac, and, if so, what is its extent or capacity? Concerning 
this question various views have been expressed by anato- 
mists and surgeons, and it is important, therefore, that it 
should be carefully examined before we pass an opinion on 
it, either affirmatively or negatively, as our decision, whatever it 
may be, must be calculated to exert no inconsiderable influence 
upon the treatment of traumatic lesions of the alimentary 
canal. Mr. John Bell, in his Principles of Surgery,* affirms 
that, "there is not, truly, any cavity in the human body, but 
that all the hollow bowels are filled with their contents — all 
the cavities with their hollow bow-els — and that the whole are 
equally and fairly pressed." That this is really so every 
one will admit; but when he declares, as he does almost 
in the same sentence, that all the viscera of the abdomen 
may be deeply wounded, and yet no blood or faeces can 
escape, he makes an assertion which is unsustained by facts, 
and which daily observations on the human subject, as well 
as experiments upon the inferior animals, wholly disprove. 
Examples of ficcal effusion, either alone or in combination 
with blood, are mentioned by a great number of pathologists, 
by Hoyerus, Ravaton, and Morgagni, of the last century; 
by Cooper, Travers, and others, of the present. Indeed, 
there is literally no end to cases of this description — a vol- 
ume would scarcely suffice to record them all; for there is 
hardly a physician, at all extensively engaged in practice, who 
has not met with them. A few years ago I assisted my col- 
league. Professor Cobb, in examining the body of a stout, ath- 
letic man, who had been stabbed in the abdomen, apparently 
with a dirk, which had entered near the umbilicus, and per- 
forated the jejunum, laying open that tube in an oblique di- 
rection to the extent of nearly half an inch. Through this 



•Vol. i, p. 487. London, 1827. 



8 Gross on Wounds of thz Intestines. 

aperture a small quantity of stercoraceous matter had made 
its way into the peritoneal sac, where it induced violent 
inflammation, of which the patient died in less than two 
days. 

Moreover, certain pathological facts clearly show the fal- 
lacy of the above opinion. In ulceration of the bowels the 
morbid action occasionally extends to the serous investment, 
which it at length perforates, leading thus to a discharge of 
fa3cal matter. Of this not less than five or six well-marked 
cases have fallen under my own observation, and numerous 
others of a similar kind are narrated by authors. This occur- 
rence must, in fact, inevitably happen whenever nature fails 
to effect adhesion in the surrounding parts, however slight the 
opening. In several of my cases the aperture did not exceed 
two lines, or the sixth of an inch in diameter, and in some 
of those that have come under the notice of other observers, 
it was still smaller, scarcely equalling the size of a crow- 
quill. Additional facts have been furnished by Smith and 
Travers, in their experiments on dogs. My own researches 
have afforded the following results. 

Having opened the cavity of the abdomen of a small slut, 
a transverse wound, half an inch long, was made into the je- 
junum, and the part returned without suture. The animal be- 
came sick soon after the operation, and evinced a disinclina- 
tion to move about. In thirty-two hours she died. The 
aperture in the bowel was perfectly patulous, with the mu- 
cous coat everted, of an oval form, and without the slightest 
attempt at reparation or adhesion to the circumjacent struc- 
tures. About six ounces of a dirty yellowish looking fluid, 
evidently of a fa3culent nature, were contained in the perito- 
neal sac; and there was extensive inflammation of the omen- 
tum, together with the serous coat of the bowels, several coils 
of which adhered with tolerable firmness to each other. 

In another experiment, the subject of which was a small 
dog, and in which the incision was of the same extent and 
direction, the results were of a similar character. The ani- 
mal became sick shortly after the operation, and continued 



Gross on Wounds of the Intestines. 



9 



in that condition for thirty-six hours, when he died. On dis- 
section, the edges of the wound were found to be in a gaping 
state, without any apparent effort at restoration; some hard- 
ened and fluid focces had escaped into the abdominal cavity; 
the bowel was red and contracted for several inches above 
and below the affected part; and the neighboring knuckles of 
intestine were agglutinated by plastic lymph. 

In a third experiment, in w'hich the wound was only four 
lines, or the third of an inch in length, and in which the 
bowel was replaced without suture, recovery occurred without 
any untoward symptoms, and without any apparent inconve- 
nience to the animal. 

Oblique wounds, six lines long, and treated without suture, 
were followed by the same result as transverse wounds of the 
same extent. Only two experiments were performed to elu- 
cidate this point. The particulars it is unnecessary to detail. 
It will suffice to say that, in one of the dogs, death took place 
in thirty-six, in the other, in forty-seven hours, from peritoneal 
inflammation, occasioned by the effusion of feculent matter. 
The wounds in both were in a gaping, patulous state, with- 
out any evidence whatever of reparation by the adhesive pro- 
cess. 

To ascertain whether a longitudinal wound, six lines long, 
would be attended with the same degree of danger, was the ob- 
ject of the next experiment. For this purpose a healthy, full 
growji dog, of moderate size, was selected. Soon after the opera- 
tion he vomited, and appeared to be in great agony; in thirty-six 
hours he died. On opening the belly, a considerable quantity 
of gas, of a highly offensive odor, escaped with a loud 
noise. Both hardened and fluid faeces were contained in the 
peritoneal sac, the enteric portion of which, especially in the 
immediate vicinity of the wound, exhibited marks of violent 
inflammation. The edges of the wound were separated to 
the extent of at least two lines, and through the opening thus 
formed the mucous membrane projected beyond the level 
of the serous covering. No attempt had been made to re-es- 



10 



Gross on Wounds of the Intestines. 



tablish the continuity of the tube by adhesions of the gut to 
the surrounding parts. 

In a second experiment, in which the wound was only four 
lines long, speedy recovery followed. The dog was a good 
deal indisposed for the first forty-eight hours, after which he 
became well and lively, and continued thus until he was 
killed on the fifteenth day after the operation. A process of 
omentum occupied the outer wound, which was nearly healed, 
the small bowels were extensively matted together, and the 
reparation of the enteric breach had evidently been eff'ected 
by the adhesion of its edges to the two neighboring coils of 
intestine. The bottom of the wound was nearly two lines 
in width at its middle, and imperfectly filled with lymph. 

A large dog, killed nine days after having been stabbed 
with the sword of a cane, two lines in diameter, presented the 
following appearances: two punctures, distant about five inches 
from each other, were found in the small bowel; the edges 
of each were in close contact, and their outer surface was 
completely covered with plastic lymph, which was quite firm, 
slightly ecchymosed, and vascular. The animal retained his 
original embonpoint, and did not appear to have suffered ma- 
terially from the injury which had been inflicted upon him. 

From the foregoing observations and experiments, the fol- 
lowing conclusions may be established: 

First — that, although there is not, in the true sense of the 
term, any peritoneal cavity, yet the arrangement existing be- 
tween it and the enclosed viscera is of such a nature as to 
admit, and that very frequently, too, with great readiness, the 
effusion of stercoraceous matter in wounds and ulcerative 
perforation of the bowels. 

Secondly— that wounds of the bowels to the extent of six 
lines, whether transverse, oblique, or longitudinal, are almost 
always, if not invariably, followed by the escape of facal 
matter, and the consequent development of fatal peritonitis. 

Thirdly — that wounds not exceeding four lines in length, 
no matter wiiat may be their direction, are not near so apt, if 



Gross on Wounds of the Intestines. 



11 



left to themselves, to be succeeded by the extravasation of 
the contents of the intestinal tube; and that, in the majority 
of cases, nature, properly aided by art, is fully competent to 
effect reparation. 

These deductions derive additional support from the follow- 
ing experiments, instituted with a view to ascertain the effects 
of wounds and punctures of different forms and dimensions; 
1. A longitudinal incision, two lines and a half in length, 
immediately contracted to one line and three-quarters, with a 
sufficient amount of eversion of the mucous lining to close 
the resultant orifice. 2. A similar wound, four lines long, 
diminished in a few seconds to three lines, by one line and a 
half in width; it assumed an oval shape, and the internal 
membrane protruded on a level with the peritoneal covering, 
leaving no perceptible aperture. 3. An oblique cut, seven 
lines in length, contracted to five, by two and a half in width, 
with marked eversion of the mucous lining. 4. A transverse 
wound, two lines and a half long, was reduced almost in- 
stantaneously to two lines in diameter: it was of a rounded 
form, and the two outer tunics of the gut retracted so as to 
expose the mucous membrane. 5. In another experiment, in 
which the incision, likewise transverse, was half an inch in 
extent, the orifice assumed a rounded, oval shape, and was 
reduced to four lines, by two and a half in width, the internal 
coat exhibiting, as in the other cases, a pouting, or everted 
arrangement. 

These observations are interesting chiefly as showing the 
efforts which nature institutes to close a breach of this kind, 
the very moment almost it is inflicted. It is doubtless 
by a process of this description that the effusion of stercora- 
ceous matter into the peritoneal sac is so generally pre\-ented 
in those cases in which the solution of continuity is of small 
extent, not exceeding, for example, a few lines in diameter, 
and where, consequently, it amounts rather to a puncture 
than a wound. The eversion of the lining membrane forms 
a striking and constant feature in injuries of this character. 



12 



Gross ore WounJs of the Intestines. 



and may be compared, in its effects, to the contraction and 
retraction observed in the extremities of a divided artery. 

It is a circumstance in the highest degree interesting, and 
worthy of notice, that the eversion of the lining membrane, 
which is so conspicuous in traumatic lesions of the alimen- 
tary tube, is never witnessed in the openings which result from 
ulcerative action. In the latter, the perforation proceeds in a 
slow and gradual manner, at the expense mainly of the mu- 
cous and fibrous lamellso, which are always destroyed to a 
much larger extent than either the muscular or peritoneal. 
Hence, by the time the ulcer reaches the surface, it is impos- 
sible for the lining membrane to protrude across it, as it 
does when the bovvel is wounded by a sharp instrument, a 
blow, or a kick. Another circumstance which no doubt con- 
tributes to produce this result, is the indurated condition of 
the serous and muscular layers immediately around the perfo- 
ration, caused by the deposition of lymph during the progress 
of the ulcerative action. 

There is thus a striking difference, as respects their imme- 
diate effects, between an opening of the bowel from ulcera- 
tion and one produced by an incised or lacerated wound. In 
the former, although it may not be two lines in diameter, 
extravasation would be almost certain; in the latter, it might 
be nearly double that size, and yet, for the reason just men- 
tioned, that event, so much to be dreaded, would be little 
likely to occur. 

It is much to be regretted that Mr. Travers, in the experi- 
ments which he instituted to illustrate this branch of the sub- 
ject, as well as in the cases which he has adduced from his own 
and the practice of others, has not specified the size of the 
lesion; a matter of such paramount importance that it is only 
surprising how it could have been overlooked. His chief 
object, however, appears to have been, not so much to deduce 
from them any practical precept in reference to the manage- 
ment of such accidents, as to show that the apprehension of 
intestinal effusion in penetrating wounds of the abdomen, is, 



Gross on Wounds of the Intestines. 



13 



in the majority of cases, without foundation. How far he 
has succeeded in accomplishing this end, I leave it to others 
to determine. 

III. — Syviptoms, Diagnosis, and Prognosis. 

The next topic into which I proposed to inquire is the 
consideration of the symptoms of wounds of the intestines. 
A few remarks under this head will be sufficient for the ob- 
ject in view. 

The symptoms of a wounded bowel necessarily divide 
themselves into two classes, into those, namely, which are 
furnished by the system at large, and those which are pecu- 
liar to the part more directly and immediately implicated. 
In regard to the first, they are such, generally, as denote a 
severe shock of the nervous system, but as they are common 
to this and other injuries, they are of little consequence in 
enabling us to make out the diagnosis. In almost all instances 
there is nausea, either alone, or accompanied with vomiting; 
these symptoms often make their appearance within a few 
minutes after the infliction of the wound, and continue with 
great obstinacy for several successive days, or, in fatal cases, 
until death relieves the patient of his suffering. They are 
commonly more violent and distressing in lesions of the small 
than of the large bowel, owing to the more delicate organiza- 
tion of the former than of the latter, and to its more inti- 
mate connexion with the stomach and the sympathetic nerves. 
The prostration of the vital powers is not always in propor- 
tion to the extent of the wound, or the danger of the case. 
Some persons, it is well-known, suffer much more severely 
from a slight than others do from a violent injury, for rea- 
sons which cannot always be explained, but which may be 
supposed, generally, to be dependent upon some constitu- 
tional peculiarity. Reaction is often postponed for ten or 
fifteen hours after the occurrence of the accident, and until it 
is fairly established there is sometimes a constant tendency 
to syncope, with an alarmed and agitated state of the mind, 
2 



I'i Gross on Wounds of the Intestines. 

which it is ahnost impossible to calm or subdue. The coun- 
tenance under such circumstances has a pale, anxious, and 
haggard expression; the pulse is small, frequent, and tremu- 
lous; the skin is bathed with clammy perspiration; the extrem- 
ities are cold; the patient tosses about in his bed; the thirst 
is urgent, as is also the desire for cool air; there are griping 
pains in the abdomen; and occasionally the discharges from 
the bowels are involuntary. Conjoined with these symptoms 
there is sometimes slight delirium with partial blindness or 
indistinctness of vision. 

The local symptoms of a wounded intestine are often as 
equivocal as those which are furnished by the constitution. 
This must, indeed, always be the case when there is no pro- 
trusion of the tube, or when the external opening is so small, 
or its direction and situation are such, as to prevent effectu- 
ally the escape of faeces or other matters. It not unfrequently 
happens that an instrument enters the abdomen, and passes 
out at the opposite side, directly in the course of the bowels, 
without in any wise interfering with them. Many interesting 
and instructive cases of this kind are recorded by w'riters on 
military surgery, as well as by civil practitioners, and seve- 
ral will be quoted hereafter in illustration of this part of 
the subject. The most characteristic signs of this lesion are, 
unquestionably, the escape of faeces, bi^e, food or foetid air 
from the external wound, and the sudden development of 
tympanites. The latter symptom, which does not appear to 
have been sufficiently insisted upon by systematic writers, as 
very few, if any, mention it, is often present when the others 
are absent, and may therefore be regarded as in some degree 
pathognomonic. Jobert thinks it is the most valuable and 
positive sign of a wound of the intestine that we can have 
when there is no external opening, or only so small a one as 
not to permit the egress of stercoraceous or other substances. 
He' relates several instances from his own practice and that 
of others, in which, by this phenomenon alone, the diagnosis 
was clearly established. The tympanites supervenes at vari- 
ous periods, from a few minutes to several hours, after the 



Gross on Wounds of the Intestines. 



15 



occurrence of the accident, and is always attended with a 
hollow, drumlike sound on percussion, with tenderness on 
pressure, and difficulty of respiration. The following cases 
will more fully explain the nature and importance of this 
symptom. 

A young man, eighteen years of age, of an excellent con- 
stitution, an apprentice in a drug-store, in a rencounter with 
a robber, in May, 1842, was stabbed with a knife in the right 
side of the abdomen, the instrument entering the anterior 
wall of the ascending portion of the colon in a transverse 
direction, and about two inches above the ileo-ccEcal valve. 
The outer wound was fifteen lines in length, and the inner 
was sufficiently large to allow the escape of a considera- 
ble quantity of faecal matter. A short time after the occurrence 
of the accident there was diffuse pain of the abdomen, with a 
discharge of blood from the anus, and at the end of twenty- 
four hours decided tympanites. The distention progressively 
augmented for four days, when it had attained an enormous 
height. From this period it slowly subsided, but did not 
entirely disappear under a month. Pressure on the abdomen 
during the first week occasioned the most exquisite pain. 
The patient finally recovered under the judicious management 
of Dr. E. S. Williams and Professor Mussey, of Cincinnati, 
where the case occmred, and where, through the politeness 
of those gentlemen, an opportunity was afforded me of see- 
ing it, during a visit which I made to that city last summer. 

A carriage-driver, sixty years of age, was kicked by a horse 
upon an old rupture in the left groin, for which he was carried 
to the St. Louis hospital of Paris. The following morning he 
had great pain in the belly, especially on pressure, and the 
swelling, which was very large and emitted a peculiar gurgling 
noise, was tympanitic. He died the next day under all the 
symptoms of gangrene or rupture of the intestine. The scro- 
tum, hernia, and belly, were all distended with gas, which 
could be readily forced from one to the other; the intestinal 
folds were agglutinated by plastic lymph; black matter was 



16 



Gross on Wounds of the Intestines. 



effused into the pelvic and abdominal cavities; and the small 
bowel was entirely torn across.* 

A young man, twenty-one years of age, was thrown from 
his carriage, the wheel of which passed over his belly. 
"When brought to the St. Louis hospital, immediately after 
the accident, the skin of the abdomen was found to be per- 
fectly natural, but he complained of great pain, and there 
was enormous tympanites, the parts on percussion sounding 
like a drum. His sufferings for eight days were very violent, 
after which they gradually subsided, and he was rapidly con- 
valescing from his injury, when, at the end of a month, an 
unexpected attack of pleuro-pneumonitis occurred, which 
quickly destroyed him. The jejunum adhered to the last 
false rib, and presented the remains of an opening, which had 
been completely closed by a sort of plug of the omentum.! 

A man affected with cancer of the rectum was admit- 
ted into the surgical ward of the St. Louis Hospital under 
the care of Mons. Richerand. The abdomen became sud- 
denl}'- tympanitic, and this distinguished surgeon at once 
pronounced the case to be one of intestinal perforation. The 
autopsy justified the diagnosis. The bowel was found to 
have given way above the seat of the disease, and thus per- 
mitted the escape of the gas upon which the distention de- 
pended. J Examples of a similar character are recorded by 
Scarpa, Sevestre, Kapeier, Marjolin, and other writers. 

Tympanites, however, does not attend all traumatic injuries 
of the intestinal canal. When the opening is very small, 
amounting rather to a puncture than a wound, the escape of 
gas will either be entirely prevented, or occur only in a small de- 
gree, owing to the protrusion of the mucous membrane, which, 
as was seen in a previous part of this essay, is a constant 
phenomenon in lesions of this description. A sort of valve 



*Jobert, Maladies du Canal Intestinal, T. i, p. (U. 
fJobert, op. cit. T. i, p. 62. 
tJobert, op. cit. T. i, p. 63. 



Gross on Wounds of the Intestines. 



is thus formed, which opposes an effectual barrier to the egress 
of foscal matter, intestinal secretions, and even air. 

A discharge of blood from the anus is another symptom 
which, in connexion with some of those already pointed out, 
is of considerable importance in the discrimination of the lesion 
before us. Still, as it may, and often does attend other inju- 
ries, it cannot be regarded as at all characteristic. The quan- 
tity of blood evacuated occasionally amounts to many oun- 
ces. In the case previously adverted to, which I saw along 
with Professer Mussey and Dr. Williams, at least two pints 
of fluid and grumous blood were discharged during the first 
three days. It began to pass off seven hours after the occur- 
rence of the injuiT, nearly unmixed with faices, and com- 
paratively fresh in its appearance. What was subsequently 
evacuated was of a darker color, and more firmly coagulated, 
as if it had been retained for sometime in the bowel. 

Equally equivocal is hematemesis, or vomiting of blood 
which may be enumerated as another, though by no means 
constant symptom of traumatic lesion of the alimentary tube. 

The degree of pain accompanying cases of this kind varies 
remarkably in different individuals, being very slight in some, 
and exceedingly severe in others. In most instances it is of 
a colicky character, though occasionally it is dull and aching, 
and it is almost constantly increased by pressure, by coughing, 
and by a full inspiration, especially if some hours have elapsed 
since the infliction of the injury. 

The wound is occasionally complicated with hemorrhage 
into the peritoneal sac, caused by lesion of the epigastric or 
internal mammary artery, of some of the branches of the 
mesentery or omentum, of the aorta or vena cava or of some 
of their immediate offsets. Unless the abdominal wound be 
large, very little blood, if any, will appear externally, but it 
will flow into the serous cavity, where it will occupy the in- 
tervals between the intestinal convolutions, descend into the 
pelvis, or be extensively diffused among the viscera. The 
amount and rapidity of the effusion will vary in proportion 
to the size of the wound and the volume of the vessel con- 



2 



18 



Gross on Wounds of the Intestines. 



cerned. When the vessel is very large and the opening con- 
siderable, the hemorrhage may be instantly fatal, or death 
may ensue in a few hours. In cases of an opposite char- 
acter the symptoms will be less urgent, and the patient prob- 
ably suffer no inconvenience, save what results from the tem- 
porary debility and faintness. The blood will soon coagulate, 
and by the pressure which it exerts upon the orifice of the 
bleeding vessel, a mechanical obstacle will be opposed to its 
further effusion. 

When the quantity of fluid poured out is considerable a 
tumor is sometimes formed, which may be easily detected by 
its prominence and hard feel. If the patient survive the im- 
mediate shock of the accident, he may die from inflamma- 
tion, caused by the clotted blood acting as an extraneous sub- 
stance. At other times the coagula are absorbed, or they 
become encysted by an exudation of plastic lymph. 

In the diagnosis of a wounded bowel important informa- 
tion may frequently be obtained, in regard to the direction, 
extent, and depth of the lesion, by a careful consideration of 
the shape and size of the vulnerating body. When the outer 
opening is so large as to admit the finger, it will generally be 
easy to determine whether the injury reaches the cavity of 
the abdomen: probing with instruments is quite inadmissible; 
it can do no good, and may occasion much harm. It need 
hardly be observed that it is highly proper, in every inquiry 
of this kind, to place the patient as nearly as possible into 
the posture in which he was at the moment of tlie accident. 
When the wounded bowel protrudes at the external opening, 
the diagnosis is at once obvious, as the nature and extent of 
the injury may be determined by simple inspection. The 
lesion, in the absence of pathognomonic symptoms, ought to 
be suspected when nausea and vomiting occur after penetra- 
ting wounds of the abdomen, accompanied with griping 
pains, great debility and faintness, jactitation, extreme anxie- 
ty, and cold sweats. The case is plain enough when there is 
a discharge of the contents of the alimentary tube, or a sud- 
den development of tympanites. 



Gross on Wounds of the Intestines. 



19 



It not unfrequently happens that an instrument enters the 
abdomen, and passes out at the opposite side, without, in the 
slightest degree, interfering with the bowels or other viscera. 
Many interesting cases of the kind are related by writers. 
I select the following in illustration of the subject. 

A young soldier received, in a duel, a thrust from a sabre 
on the anterior part of the abdomen, a little above and to the 
right of the umbilicus. The walls of the belly were divided, 
and a considerable mass of omentum protruded through the 
opening. The patient was removed to the hospital, where 
every attempt was made to reduce the prolapsed parts, but 
without success. Blood was freely abstracted from the arm, 
leeches, cups, and fomentations were applied to the abdo- 
men, and perfect quietude was enjoined; in short, every thing 
was done to prevent peritoneal inflammation. Eight days 
after the reception of the injury the extruded omentum was 
cut ofT, after which the wound became covered with healthy 
granulations, and at the end of fiveweeks the man was nearly 
well.* 

The following case, mentioned by Sir Astley Cooper,t is 
strikingly illustrative of the manner in which the intestines 
glide away from the edge of the instrument. He was called 
to a female whom he found lying on the floor, weltering in 
her blood, from the infliction of four wounds upon her throat, 
in an attempt to commit suicide. Having closed these with 
sutures, his attention was directed, by some incoherent re- 
mark which she made, to her abdomen, where he found the 
bowels exposed by a wound reaching nearly from the pubes 
to the ensiform cartilage of the sternum. After cutting her 
throat with a razor, she had ripped up her belly with it, and 
let out her bowels, which were still distended with air, and 
had not sustained the slightest injury. 

Dr. Hennen statesj that he was witness to the recovery of 



*Medico-Chir. Review, vol. ix, p. 527. 
+0p. cit., vol. ix, p. 529. 

tPrinciples of Military Surgery, p. 319. Phila., 1830. 



20 



Gross, on Wounds of the Intestines. 



a soldier who was shot through the body with a ram- 
rod at the siege of Badajos, in 1S12. The instrument enter- 
ed the front of the abdomen, and actually stuck in one of the 
transverse processes of the vertebrae, from which it could not 
be disengaged without force. An analogous case is related 
by Dupuytren.* 

A man in a fit of severe grief resolved to put an end to his 
existence, and for this purpose rushed with all his force 
iigainst the point of a sword, which he had previously fas- 
tened in the wall of his apartment. So completely was the 
abdomen transfixed that the point of the weapon stuck out 
ior eight or ten inches on the right side of the spine. When 
Dupuytren saw him, he seemed to sufTer but little pain, and 
ttiere was no symptom of any extravasation, or, indeed, of a 
wound of any of the abdominal viscera. It required conside- 
rable force to withdraw the sword. By repeated bleedings 
and the employment of a very rigid antiphlogistic regimen, 
the patient speedily recovered. 

Richard Wisem:m mentions the case of a young man who 
was run through with a rapier, which entered at the right 
hypochondriac region, and passed out at the back. On the 
the following day his skin was hot, and the pulse some- 
what accelerated, but there was no tension of the abdomen, 
tolic, vomiting, or any thing denoting injury of the in- 
testine, or any other viscus, and he recovered in a very 
short time. "Thus," says Wisemea, "it frequently happeneth 
that a sword passeth through the body without wounding 
any considerable part.f Two similar cases are recorded, 
one by Lamotte,J and the other by Garangeot, in each of 
which a sword passed directly across the cavity of the abdo- 
men, without injuring a single fold of the intestinal tube. 

Numerous instances of penetrating gunshot wounds of the 



•Medico-Chir. Review, vol. xxi, p. 301. 
fChirurgical Treatises, 4to., p. 373. London, 1676; 
JTraite Complet de Chirurgie, T. ii. 



Gross on Wounds of the Intestines. 



21 



abdomen are recorded, in which the bowels appear to have 
completely escaped injury. A case, which was evidently 
of this nature, is mentioned by Dr. John W. Richardson, of 
Tennessee, in the fourth volume of the Western Journal of 
Medicine and Surgery.* The ball, which weighed two 
drachms and a half, entered the abdomen on the right of the 
median line, and issued midway between the last rib and the 
sacro-iliac symphysis, immediately on the right side of the 
spine. There was no escape of gas or ffeculent matter from 
the wound; some bloody urine was discharged soon after the 
infliction of the injury, and for the first eight or ten days 
there was considerable tension with soreness and swelling of 
the abdomen. The whole treatment was very simple, and 
the patient recovered in less than a month. 

When the ball does not pass entirely through the body, it 
may be retained in the peritoneal cavity, or, if it wound 
the bowel, it may at once fall into the latter, and be dis- 
charged by stool. In the former case the foreign body excites 
adhesive inflammation, by which it becomes encysted; after 
it has remained in this condition, however, for a while it 
usually induces suppurative action, which gradually extends 
to the coats of the intestine, and finally produces perforation, 
whereby an outlet is established for its evacuation. When 
the extraneous substance is very small, as, for example, a 
shot, or even a small bullet, it occasionally continues encysted 
for many years, or even during the remainder of life, without 
occasioning any ill effects. An instance in which a number 
of encysted shot were found in the peritoneum recently 
occurred in the Louisville Marine Hospital, in an old man 
who had been wounded by a musket ten or twelve years 
previously. He soon recovered from the injury, to which he 
never referred any of his subsequent ailments. 

I shall conclude this citation of authorities with the follow- 
ing extraordinary case recorded by Dr. Hennen, in his work 



* This case is reported as having involved the colon and small intes- 
tines, without any evidence whatever that this was the fact. 



22 



Gross on Wouyids <f the Intestines. 



on Military Surgery. A soldier of the Brunswick corps was 
wounded on the 16th of June, 1815, by a grape shot, whicli 
struck the right arm near the elbow, the articulation of 
which was destroyed. An English surgeon amputated the 
limb some hours after. The patient remained that night at 
Genappes. Next morning he observed blood flowing through 
the bandages, and requested Dr. Spangenberg, physician-in- 
chief to the Hanoverian army, to examine the arm. He 
found the humerus split as far as the joint, and with the con- 
sent of the patient immediately extracted it. After having 
dressed the parts, the man complained of pain in the abdo- 
men, which was ascertained to proceed from a wound caused 
by a grape shot, which had passed through the exterior part 
of the belly, leaving two openings, one in front and the other 
behind, through each of which a portion of intestine protru- 
ded, not injured or inflamed, but in the natural state. The 
bowel, smeared with oil, was carefully reduced, and the two 
apertures were covered with adhesive plaster. The patient 
was brought to the hospital at Laecken, on the 19th of June, 
with moderate fever, and very little pain in the abdomen, or 
in the wound of the arm. The functions of the intestinal 
tube were not disturbed. He took little or no medicine; in 
four weeks the sores in the arm were cicatrized, and those of 
the abdomen, which were slightly affected with gangrene, 
in about three months. 

The prognosis of wounds of the intestines must necessarily 
be influenced by a great variety of circumstances, such, par- 
ticularly, as the extent of the mischief, the nature of the vul- 
nerating body, and the state of the patient's health at the 
time of the accident. A small and simple lesion will be much 
more likely to turn out favorably than one involving a large 
surface, or one complicated with injury of some other organ, 
or the perforation of a large vessel. It is also less serious in 
an incised than in a contused or lacerated wound, and in a 
superficial than a deep one. Persons occasionally perish from 
the most trivial accidents of this kind, from the mere shock 
probably of the nervous system; they lie in a pale and ex- 



Gross on Wounds of the Intestines. 



23 



iiausted condition, and death takes place unpreceded by reac- 
tion. On tiie other hand, recovery sometimes occurs under 
circumstances apparently the most desperate and unpromising. 
No certain rule can, therefore, be laid down in respect to the 
prognosis of wounds of this description; which, however, 
must always be considered as severe accidents, likely to be 
followed by the worst consequences. Wounds of the large 
bowel v\ere regarded by the ancient surgeons as less serious 
than those of the small; a view in which most modern au- 
thors seem to concur. The reason of this difference is, first, 
the more fixed condition of the lower portion of the tube; 
secondly, its more capacious calibre; and thirdly, the more 
solid nature of its contents. These circumstances may all be 
supposed to be favorable to the prevention of the effusion of 
feecal matter. Extravasation will also be less apt to occur 
when the bowel is empty than when distended. 

When the contents of the bowel are effused over the peri- 
toneum, death is sure to take place from the effects of inflam- 
mation. Occasionally, as was before intimated, life seems to 
be destroyed by the shock sustained by the nervous system 
within a few hours after the accident, and before the constitu- 
tion has had time to rally. The faecal extravasation, when 
slight, is sometimes limited by the deposition of plastic lymph, 
and the discharge of it is ultimately promoted by the forma- 
tion of an abscess; or chronic action is established in the 
serous membrane, and the patient, after weeks or months of 
suffering, sinks under the exhausting influence of the malady. 
In the great majority of instances, however, death is induced 
by acute peritoneal inflammation. The symptoms presented 
are violent burning pain of the abdomen with great tenderness 
on pressure; intense thirst; a sharp, frequent, and contracted 
state of the pulse; constipation of the bowels; coldness of the 
extremities; constant wakefulness; great anxiety and restless- 
ness. In the latter stages there is generally some degree of 
nausea with occasional vomiting; the pulse is weak and flut- 
tering; the surface is bathed with a cold clammy sweat; the 
features are collapsed; the breathing is oppressed and labori- 



24 



Gross on Wounds of the Intestines. 



ous; the belly extremely tense and tumid; the patient is ha- 
rassed with cough, his strength rapidly forsakes him, and 
he dies under all the symptoms of one sinking from the 
effects of mortification. The attack rarely continues beyond 
forty-eight hours, and often terminates fatally in a much 
shorter period. The appearances after death are always 
well-marked when the disease has been protracted. The 
peritoneal surface is highly inflamed, the bowels are covered 
with lymph, and the abdominal cavity usually contains a 
small quantity of turbid serum. The intestinal coils are fre- 
quently united to each other and to the neighboring parts, 
and on penetrating the belly there is almost always an escape 
of foetid gas. 

IV. — Mode of Reparation. 

I come, in the next place, to consider the process employed 
by nature in repairing wounds of the intestinal tube, and the 
mode in which she disposes of the ligature used in securing 
their edges. 

If a small^ circular ligature be drawn firmly round the bowel 
of a dog, or other animal, the resulting effects will be very 
similar to those which attend the ligation of an artery. The 



opposite surfaces will not only 
be forced into close contact with 
each other, but it will produce at 
the same time a complete division 
of the mucous coat. If the cord 
be pulled very tightly, there will 
be in addition, especially in young 
subjects, a partial separation of the 
cellulo-fibrous lamella and of the 
muscular fibres. These effects I 
have repeatedly witnessed in my 
experiments on dogs, and they 
may be readily produced in the 




human body after death. If a flat ligature be used, even when 



Gross on Wounds of the Intestines. 



25 



il is drawn with considerable firmness, the opposite surfaces of 
the tube are merely brought into contact, without any rupture 
of the substance ofanyof the tunics. The only exception to this 
is where the animal is very ^^^..■.''vmp^ 



Soon after an operation of this kind, in which a narrow 
circular ligature is used, inflammation is set up, plastic lymph 
is deposited upon and around the constricted parts, ulcerative 
absorption is established, and the cord at length works its 
way into the intestinal tube, where it is discharged along 
with the fasces. The period required for the detachment of 
the ligature may be supposed to be influenced by various cir- 
cumstances, the principal of which are referable to the form 
and size of the foreign substance, together with the force with 
which it is applied, the thickness of the different tunics of the 
bowel, the age of the subject, and the state of the general 
health at the time of the operation, as .. ell as immediately 
after it. In a small but full grown dog, killed at the end of 
the third day after the experiment, the ligature, which was 
round and narrow, had found its way through more than one- 



young and the parietes of the 
bowel are unusually tender; 
in which case there will be ^ 
occasionally a slight division 
of the lining membrane, but 
not of the muscular fibres. 
When a narrow ligature is 
used, the parts above and be- 
low it are so closely approxi- 
mated that they touch in the 
greater portion of their cir- 
cumference; a circumstance 
which must necessarily exert 
a most favorable influence | 
over the reparative process i 
and the re-establishment of I 
the continuity of the canal. 





3 



26 



Gross on Wounds of the Intestines. 



half of the circumference of the tube, and in another animaj 
of the same land, which died from the effects of the operation 
thirteen hours later, the progress of the foreign body wa? 
still greater. In the latter, indeed, the cord had entirely dis- 
appeared, having lost its hold, and escaped into the bowel, in 
which, after a minute examination, it was discovered at the 
distance of several feet from the seat of the injury, surround- 
ed by fajcal matter. In both cases the continuity of the parts 
was thoroughly re-established by an abundant deposition of 
lymph, which, notwithstanding the brief period that had 
elapsed, exhibited already well-marked traces of organization. 
The bowel, however, presented in each instance a constricted 
appearance; and in one of the animals, that, namely, which 
was killed at the end of the third day, the opposed mu- 
cous surfaces were still in close contact, no attempt having 
apparently been made to restore that portion of the tube. In 
the other the parts were not only perfectly continuous with 
each other, as has just been intimated, but the cavity was par- 
tially re-established. In a third experiment, performed on a 
middle-sized dog, not more than eighteen months old, the 
ligature was found lying at the seat of the constriction, where 
it was retained by a layer of plastic lymph, which had sealed 
up, as it were, the surface of the fissure in the mucous tunic. 
The canal of the bowel was completely restored, and the bond 
of connexion between the divided parts firm and organized. 
The animal was killed on the eleventh day. 

The following experiment was performed by Mr. Travers, 
and is recorded in his work on wounds of the intestines. A 
ligature of thin pack thread was firmly tied around the duo- 
denum of a dog, so as completely to obstruct it. The ends 
of the string were cut off, and the part returned. On the fif- 
teenth day, his cure being established, he was killed. A por- 
tion of omentum connected to the duodenum was lying 
within the wound, and the folds contiguous to the strictured 
intestine adhered to it at several points. A slight circumfer- 
ential depression was observed in the duodenum, and the mu- 
cous surface was more vascular, as well as of a deeper color, than 



Gross 071 Wounds of the Intestines. 



27 



usual. A transverse fissure marked the seat of the ligature. 
The edges of the sections were distinctly everted, and the 
appearance corresponded with that of the union by suture. 

The lymph which is effused upon the external surface of 
the bowel, consequent upon the operation, gives the part at 
first a rough uneven appearance; but after a few weeks, sooner 
or later, according to circumstances, it undergoes a sort of 
modelling process, and hence, if the animal survive several 
months, it is generally no easy matter to determine the seat 
of the injury. In a dog which was killed four months after 
the experiment was performed, the reparation was so perfect 
that, had it not been for the attachment of a small process of 
omentum, it would have been impossible, by mere external 
inspection, to discover the place where the cord was originally 
applied, such were its smoothness and polish. Nor was this 
confined solely to the outer surface of the tube. Internally 
the cicatrization was almost as complete, the continuity of the 
mucous membrane having been every where re-established. 
There w^as scarcely even a seam at the original seat of the 
constriction. 

It will thus be perceived that, from the rapid manner in 
which the ligature is detached, there is no danger thai the 
animal will suffer much inconvenience from the want of a 
passage. Indeed, when the ligation is made in the small 
bowel, or high up in the large, the alvine discharge may go 
on with the same facility as before, making allowance of 
course for the pain which must necessarily attend an opera- 
tion of such severity. 

Effects similar to the above are produced when a ligature is 
applied round the edges of a small wound, that is to say, from 
two to three lines in diameter, provided it be drawn with 
sufficient firmness not to slip off. The cord gradually cuts 
through the different coats of the bowel, and the continuity of 
the canal is re-established by the effusion of plastic lymph 
upon the constricted part. The process of reparation, how- 
ever, is not so speedily completed, owing to the breach being 
much wider than when a ligature is simply cast round the 



28 Gross on Wounds of the Intestines. 



tube. In this case the mucous membrane is reproduced only 
after a long time, and the amount of lymph required is pro- 
portionally much greater. The ligature is detached at a pe- 
riod varying from five to ten days. 

Wounds and punctures of the bowel, unaccompanied by the 
effusion of fcecal matter, heal, when left to themselves, either by 
the adhesion of their edges to the surrounding parts, or by the 
deposition of b'mph upon their surface and the gradual approxi- 
mation of their lips. In the majority of cases the reparation is 
probably effected by the former method; since there is always a 
great tendency in the wounded structures to attach themselves 
to those in their immediate vicinity. Even wounds of large 
size are occasionally repaired in this manner. In some in- 
stances, again, the breach is closed by a piece of omentum, 
which projects into it, and fills it up like a tampon. When 
this happens the serous membrane is firmly fixed to the edges 
of the opening, and the part which corresponds with the in- 
terior of the canal and assists in maintaining its continuity, is 
eventually absorbed; an occurrence which leads to the grad- 
ual approximation of the lips of the wound and their ultimate 
re-union. Jobert thinks that this mode of reparation is not 
uncommon, an opinion in which my observations do not in- 
duce me to concur. That it takes place occasionally is cer- 
tain, for I have several times witnessed it in my experiments. 
He refers to a case, reported by Dr. Qurcial of Toulouse, 
of perforation of the jejunum, in which the epiploon project- 
ed into the opening, and thus effected a cure.* All the older 
surgeons, down to La Faye, Palfin.f and even Sabatier,J. 
"believed that wounds of the intestines never united, except 
through the intervention of the peritoneum, the omentum, or 
some of the neighboring viscera. 

In mortification of the bowels, especially when occurring 



* Traite des Maladies du Canal Intestinal, T. i, p. 66. 
t Anatomie Chirurgicale, T. ii, p. 66. 
X Medecine Operatoire, T. i, p. 33. 



Gross on Wounds of the Intestines. 



29 



in small patches, the mode of reparation appears to be simi- 
lar to that which takes place when a wound or puncture is 
left to itself. By the time the eschar is detached the edges 
of the breach will have formed adhesions to the circumjacent 
parts, by which the effusion of ftecal matter will be effectually 
guarded against. Where this is prevented the patient dies 
from peritoneal inflammation, or an artificial anus is estab- 
lished. 

The subject of gunshot wounds of the intestines appears to 
have been more profoundly investigated by Baron Larrey 
than by any other surgeon. He divides the curative process 
into four stages. In the first, the bruised and lacerated tis- 
sues are deprived of their vitality, to an extent varying 
according to the amount of the injury they have sustained. 
In this respect a gunshot wound of the alimentary canal does 
not differ from that of any other part of the body. In the 
second stage, the eschar is detached, and the opening gives 
vent to fasculent and purulent matter, which continues to 
escape for several weeks or even months. During the third 
stage, the discharge gradually diminishes, and at last ceases 
altogether to appear externally. The union of the wound 
constitutes the fourth stage. The corresponding textures 
gradually approach each other, and, cicatrizing from within 
outwards, the whole chasm is at length completely filled up: 
the primitive adhesions become absorbed, and there only 
remains a slight contraction of the intestinal tube at the 
wounded part * 

When sutures are employed the mode of reparation is essen- 
tially alike, whatever may be their form. The inflammation 
which is lighted up induces an effusion of lymph, which is 
speedily followed by adhesion of the injured coil to the neigh- 
boring structures, among which it is sometimes completely 
hurried. At other times no such adhesion occurs, but the 
affected part throughout the entire line of suture is coated 



* Medico-Chirurg. Review, vol. xvi, p. 58. 
3 * 



30 



Gross on Wounds of the Intestines. 



with a layer of plastic matter, by which the continuity of the 
serous surface is finally re-established, and the threads used 
in sewing up the wound are concealed from view. In almost 
all cases — certainly in eight out of ten — there is an attach- 
ment of the omentum to the surface and edges of the wound, 
which thus assists, in an eminent degree, in the process of 
restoration. I speak now of course only of what I have no- 
ticed in dogs; whether the same thing takes place so readily, 
and to the same extent, in the human subject, my information 
does not enable me to determine. Probably it doas not, as 
the epiploon is generally much smaller in man than in some 
of the inferior animals, especially in the canine races. The 
attachment of this membrane to the surface and edges of the 
wound is a very different matter, it will be observed, from 
the projection of it into the breach, in the manner pointed 
out and so strenuously insisted upon by Jobert. We have 
already seen that the latter is comparatively rare, while the 
other, on the contrary, is exceedingly frequent. 

This extraordinary tendency to adhesion in the external 
surface and edges of the wound to the parts around it, is no- 
thing more than what might be expected when we reflect 
upon the nature of the peritoneum, and its invariable dispo- 
sition, when inflamed, to pour out lymph. But it is oth- 
erwise with the mucous membrane. Here the process of 
re-union is not only much slower but much less perfect; 
lymph is furnished very sparingly, or in quantities barely 
sufficient to fill the chasm between the margins of the wound; 
and, owing to the heterogeneous and irritating nature of the 
contents of the tube, a long time must necessarily elapse be- 
fore it can become an organized or living intermedium. The 
little narrow band thus formed adheres firmly to the bottom 
of the wound, but very slightly, if at all, for some days, to 
its edges. Gradually, however, it becomes more and more 
dense; vessels extend into it from the circumjacent parts; its 
margins are flattened down; and, after a period varying from 
a few weeks to as many months, the adhesion is finally com- 
pleted. Subsequently, or, indeed, while the changes just 



Gross on Wounds of the Intestines. 



3! 



adverted to are still in progress, the new matter is nearly all 
absorbed, the wound greatly diminishes in width, and when 
the cicatrizing process is perfected merely a small depression 
or seam remains, to indicate the original seat of the injury. 
The whole process may be compared to that which nature 
employs in the reparation of ulcers of the mucous lining of 
the small and large bowel. 

This, however, is only one mode in which the restoration 
of the mucous surface is effected. _ Another, though by no 
means a frequent one, is by granulation. It has been already 
stated that, owing to the irritating and heterogeneous charac- 
ter of the contents of the bowel, the lymph which is depos- 
ited upon the wound is very tardy in becoming organized, 
and it may now be added that this process is occasionally 
entirely prevented, ihe substance in question being either 
destroyed or removed by the faecal matter as it passes over 
the affected part. When this happens, nature, faithful to her 
duties, makes an effort to repair the breach by the formation 
of granulations, as in similar injuries of other textures. The 
process under these circumstances is generally much more 
tardy than in the previous case, the cicatrization is also lesa 
complete, and the tube is much more apt to be puckered im- 
mediately around the seat of the injury. Mr. Travers seems 
to doubt that the fissure in the mucous lining is ever filled by 
gi-anulation. "I had been led to expect," says he, "that the 
interstice of tlie villous coat would be filled by granulation, 
and that the substance of the cylinder would in this way be 
restored at the place of division. But finding the eversion of 
the villous edges uniform and permanent, it seemed doubtful 
if such a process could be set up, as perfect surfaces were 
opposed to each other. It is also not inconsistent with the 
indisposition of mucous surface to the adhesive inflammation 
to infer that it does not readily admit of the granulating pro- 
cess, which is only an advanced stage of that inflammation."* 



- Op. cit., p. 131. 



32 Gross on Wounds of the Intestines. 

I quote the language of this distinguished author, in order 
that his meaning may be fully understood. I am not aware 
that a similar opinion has been expressed by any other writer, 
and how so accurate an observer should have arrived at so 
erroneous a conclusion cannot be easily conceived. That 
granulations are formed on mucous surfaces is a matter of 
daily observation, and my researches have abundantly satisfied 
me that they are occasionally concerned in the restoration of 
the villous portion of a wounded bowel. The process of 
course is difficult; it must be so from the very nature of the 
mucous tissue, indisposed as it is to pour out plastic lymph; 
but this does not prove that it may not take place. 

This writer has made another remark in relation to this 
subject not less erroneous, when he asserts that the adhesion 
which takes place between the mucous surfaces within a few 
hours after their connexion by suture is in no instance per- 
manent, but that it is destroyed by the retraction of the 
divided parts when the ligatures drop off. Such an occur- 
rence does undoubtedly sometimes take place, but I have re- 
peatedly observed the reverse, and there is reason to believe, 
judging from the results of my own researches, that this hap- 
pens much more frequently than is commonly supposed. 
Several days, often as many as eight or ten, must of necessity 
eJapse before the sutures are detached; a period which is more 
than sufficient, in the plurality of cases, for the agglutination 
af the villous lips of the wound by plastic lymph. The appo- 
sition of the parts, moreover, is eminently favored by the crip- 
pled and paralysed condition of the muscular fibres at the 
seat of the injury, and by the tendency of the mucous mem- 
brane to eversion at the moment of the accident. 

From the foregoing observations it is evident that the pro- 
cess of re-union is the same, whether the bowel be encircled 
partially or wholly by a ligature, whether we employ the 
suture, or, lastly, whether the wound, provided it be not too 
ample, be entirely intrusted to the resources of nature. In 
each case the restoration is effected through the medium of 
plastic lymph, poured out as a consequence of inflammation. 



Gross on Wounds of the Intestines. 



33 



and undergoing, sooner or later, a certain degree of organiza- 
tion. 

The manner in which the ligatures are detached varies, as 
might be expected, according to the mode in which they are 
applied. Both in the interrupted and continued sutures, with 
their different modifications, the threads, provided their ex- 
tremities are cut off close to the surface of the wound, inva- 
riably fall into the alimentary canal, along with the contents 
of which they are afterwards evacuated. This, indeed, may 
be laid down as an axiom, to which I saw no exceptions in 
any of my experiments, and which fully confirm, in this par- 
ticular, as well as in many others, the researches of Smith, 
Thomson, Travers, and Cooper. The fact that the foreign 
body employed in making the suture is thus disposed of 
appears to have been first noticed, at all events hinted at, by 
Mr. Benjamin Bell in his System of Surgery; but it remained 
for two of the gentlemen whose names have just been cited, 
namely, Mr. Thomson and Mr. Travers, to settle the question 
by a direct appeal to experiments on the inferior animals- 

The same circumstance, as was previously intimated, occurs 
when a ligature is cast around a loop of intestine, or when 
it is employed to encircle the margins of a small aperture, 
whether caused by injury or mortification. If, on the other 
hand, the extremities are permitted to hang out at the exter- 
nal wound, they will be discharged outwardly instead of in- 
wardly, as in the former case. When the threads, through 
accident or negligence, slip beyond the reach of the operator, 
and escape into the peritoneal cavity, they will either induce 
fatal inflammation, or lymph will be poured out and they will 
thus become encysted, or they will excite ulcerative action in 
the coats of the bowel and find their way into it, or they will 
be evacuated through the opening in the wall of the abdo- 
men. 



34 



Gross on Wounds of the Intestines. 



Y.— Treatment. 

Leaving this subject, I proceed to speak of the treatment 
of wounds of the intestines; a topic which necessarily in- 
volves the consideration of the suture in all its naodifications 
and varieties. 

In entering upon the discussion of this subject, for the elu- 
cidation of which my researches were mainly instituted, the 
first question that presents itself is, are there any circumstan- 
ces in which the surgeon should feel himself justified in re- 
turning into the abdomen a wounded bowel without sewing 
it up, and, if so, what are they? This is a point, it must be 
conceded, of paramount importance, since it closely concerns 
not only the reputation of the practitioner, but, what is of 
much greater moment, the fate of the sufferer. 

Penetrating wounds of the abdomen are not necessarily 
attended with protrusion of the bowels. Far from it. It is 
well-known that serious mischief is frequently inflicted, and 
yet, owing to the small size of the external opening, to the 
position of the body at tlie time of the accident, or to some 
other cause, there is not the slightest prolapse. In a case of 
this kind it does not matter, as a general proposition, what 
may be the extent or direction of the wound; whether, in 
other words, it be small or large, oblique, transverse, or longi- 
tudinal, since the treatment is to be conducted solely upon 
general principles, like that of any other internal or penetra- 
ting wound whatever. No probing is to be done, no dilata- 
tion practised, no suture employed. All that is required is to 
keep the patient quiet, and to resort to such means as are 
calculated to prevent inflammation, or, if this should arise, to 
limit its action. This is all that sound surgery demands, all 
that common sense indicates. Still, as there are no rules in 
grammar without exception, so there are very few, if any, in 
the healing art that do not admit of some deviation from 
established usages. This I believe to be eminently true in 
regard to the present subject. While, therefore, I would con- 



Gross 071 Wounds of the Intestines. 



35 



demn as much as any one, and in language as emphatic as it 
is possible to express it, an indiscriminate recourse to the 
means just referred to, or not dilate the external wound and 
search for the injured bowel, with the view of sewing it up, 
simply because the patient had been hurt, I believe that cir- 
cumstances may occasionally occur in which such a practice 
would not only be proper, but highly necessary to the safety 
of the individual. Let us, for the sake of being more fullj' 
understood, suppose a case: A man, after having indulged 
in a hearty repast, receives a penetrating wound in the 
abdomen from the thrust of a dirk or knife; the bowel is 
pierced, or, it may be, nearly divided, and there is a copious 
discharge of foscal matter, both externally and into the peri- 
toneal cavity, as is evinced, in the latter event, by the excru- 
ciating pain, the gastric oppression, and the collapsed condi- 
tion of the sufferer. Here the most prompt and decisive 
measures must be resorted to, or the person will perish from 
peritoneal inflammation with as much certainty as if his skull 
had been fractured and a portion of his brain let out. It will 
not do for the surgeon to fold his arms, and look upon the 
scene as an idle and uninterested spectator. Far otherwise. 
He has a duty to perform, and that duty consists in dilating 
the external wound, if it be not already sufficiently large, in 
hooking up the injured bowel, and in closing the solution of 
continuity with the requisite number of stitches, at the same- 
time that the effused matter is carefully removed with tepid 
water and a soft sponge. All wiping must of course be stu- 
diously avoided, if it be possible to do it, as this would add 
much to the risk of peritonitis. After the bowel is exposed, 
and this should be done freely, if necessary, the water is to 
be pressed from the sponge so as to run over the affected 
surface in a full stream. This method, as I know from nu- 
merous trials, not only removes any foreign substance more 
easily than wiping, but is much less apt to be followed by 
unpleasant consequences. 

By the above procedure, which, under the circumstances 
pointed out, I should never hesitate to pursue, the patient is 



36 



Gross on Wounds of the Intestines. 



not placed in a worse condition than a female who has under- 
gone the Caesarian section, or a person whose abdomen has 
been ripped up in the first instance; recovery from both of 
which is not, as is well-known, of unfrequent occurrence. A 
case in which a most extensive wound of the belly, with 
complete division of the ileum, and serious lesion of the 
tlioracic cavity, was successfully treated by Mr. Gallon, of 
Scotland, is reported in the twelfth volume of the Edinburg 
Medical and Surgical Journal, and another, in which still 
more frightful mischief was inflicted by a cannon-ball, and yet 
the man got well, is mentioned in Hennen's Military Surgery, 
and will be found in another part of this essay. A number 
of similar examples are scattered through the records of the pro- 
fession, and could the experience of practitioners generally be 
ascertained in regard to this point it would be found, I doubt 
not, to afford a vast amount of additional evidence illustrative of 
this important subject. The truth is, the fatality of penetrating 
wounds of the abdomen has been greatly overrated. Inju- 
ries of this kind have been a sort of bugbear with surgeons 
and physicians, not so much from what they themselves have 
witnessed as from what they have heard from others; and 
hence a prejudice has arisen against the infliction of wounds 
and even punctures upon the peritoneum which has "grown 
with our growth and strengthened with our strength" until it 
has become almost impossible to eradicate it. 

In making these remarks respecting the dilatation of the 
outer wound, for the purpose of enabling us to search for the 
injured bowel, let it be understood that I would recommend 
the practice only under particular circumstances. These cir- 
cumstances have been already pointed out, and it is not neces- 
sary, therefore, to dwell upon them in this place. 

When there is reason to suspect, from the nature of the 
vulnerating body, that the opening in the intestine is com- 
paratively small, not exceeding, perhaps, the third or fourth of 
an inch in diameter, it would be extremely improper, if not 
absolutely unjustifiable, to search for the bowel with the view 
of sewing it up. Such a step, indeed, could not be too 



Gross on Wounds of the Intestines. 



37 



strongly reprobated, as it would seriously complicate an injury 
which, if left to itself, naight easily heal. 

The above remarks, with the reasoning founded on them, 
are fully borne out, if I mistake not, by some of the facts cited 
in a previous part of this inquiry, in relation to the escape of 
faecal matter from the alimentary canal, when laid open to 
the extent of from four to six lines, whether longitudinally, 
transversely, or obliquely. In all cases of this kind, with 
scarcely a solitary exception, death is produced in from thirty- 
six to fortj'-eight hours by peritoneal inflammation. Mr. 
Travers, with many other respectable surgeons, is, I am aware, 
strongly opposed to the practice of dilating the abdominal 
wound and searching for the injured bowel, on the ground 
that the intestinal aperture retains its apposition with the pa- 
rietal orifice; but he has adduced no experiments, or facts of 
any soi-t, in support of his conclusion, which is, besides, at 
variance with the existing state of our knowledge in relation 
to the subject. My own researches, at all events, have led 
me to a different result, and I can therefore see no just rea- 
son why the suggestion which I have ventured to throw out 
should not be adopted under the restrictions indicated. 

The next topic into which I shall inquire is the conduct 
which the practitioner should observe when he is called to a 
penetrating wound of the abdomen, attended with protrusion, 
but no particular injury, of a poi-tion of the alimentary canal. 
Cases of this description are by no means unfrequent, and 
they occasionally happen when the external opening is so 
small as to render it seemingly impossible for any prolapsion 
to take place. By the older surgeons such injuries were 
often treated in the most barbarous manner, and it is not im- 
probable that serious harm is sometimes done by the ignorant 
and timid in our own day. Instead of reducing at once the 
extruded intestine, a procedure sanctioned both by theory 
and experience, a great deal of time used to be wasted 
in fomenting the part, in the vain hope that this would 
promote recovery; and when at length, by the delay thus 
occasioned, the gut became too painful to be replaced, instead 

4 



38 



Gross on Wounds of the Intestines. 



of dilating the outer wound, they did not hesitate to leave 
it ill its exposed situation; a practice which, as might have 
been supposed, was speedily followed by the death of the 
patient, or, what is scarcely less pitiable, an artificial anus. 

It is perfectly plain that in such a case the part should be 
at once restored, without the loss of a moment. It is cer- 
tain that no good can be done by delay, while it is equally 
clear that it may be productive of much harm. Before the 
surgeon proceeds to the operation, the patient should be 
placed in the best possible position for relaxing the abdominal 
muscles. For this purpose he should lie on his back, the head 
being supported by a pillow, the pelvis elevated higher than 
the shoulders, and the lower extremities bent at the hips and 
knees. If the bladder be much distended, it should be previ- 
ously emptied, and the patient should refrain from coughing, 
holding his breath, or any similar efforts calculated to impede 
the reduction. In a word, he should conduct himself pre- 
cisely as if he were about to undergo an operation for stran- 
gulated hernia. 

When these arrangements are effected, the surgeon, stand- 
ing at the side of the patient that may be most convenient 
to him, takes the bowel into the left hand, while with the 
right he gently pushes it back, taking care to begin with the 
part which was protruded last, or which is nearest the wound. 
These efforts are to be continued until the whole slips into 
the abdominal cavity, when the external opening is to be 
closed in the manner to be pointed out presently, and the 
case treated upon general principles. Proceeding slowly and 
cautiously in this wise, the largest protrusions may gene- 
rally be replaced without much difficulty, without inflicting 
any undue violence upon the patient, or without endangering 
the result by peritoneal inflammation. Nevertheless, it is 
sometimes almost impossible to effect the reduction, even 
when the prolapsion is inconsiderable, owing to the smallness 
of the external orifice, to the distended condition of the bowel, 
or to the spasmodic action of the muscular fibres, or to all 
these causes combined. Be this as it may, the best method 



Gross on Wounds of the Intestines. 



39 



under these circumstances is to enlarge the wound to the re- 
quisite extent by means of a probe-pointed bistoury, cau- 
tiously insinuated between the gut and the resisting parts. 
Some of the older surgeons, as Pare, Low, and Garangeot, 
were in the habit, when the difficulty depended upon infla- 
tion, or gaseous distention, of making punctures in the bowel 
to evacuate the contained air; a practice which was after- 
wards embraced by Gooch, Sharp, Sabatier, Chopart and De- 
sault. The plan, as originally suggested, consisted in making 
the punctures with a small needle, which was replaced by a 
large round one in the hands of Chopart and Desault, who 
have described the operation with much minuteness. The pro- 
cedure, however, was pointedly condemned by Blancard and 
La Faye, on the very sufficient ground of its inefficacy, as 
well as danger, and is now scarcely ever thought of, except 
as a matter of scientific curiosity. Others have recommended 
the substitution of a small trocar, but the same objections lie 
against it as against the use of the needle. 

In our attempts to restore the bowel to the abdomen, it 
is all important to know that it has actually slipped into its 
natural situation. The i-oute which the w^ound follows is 
occasionally very devious, or it may happen that there 
is a slight detachment of the peritoneum round the edges of 
the inner orifice, produced either in the first instance, or by 
the finger of the surgeon in his efforts at reduction. In either 
case, a most serious error may be committed by supposing 
that the protruded parts have been returned, when in reality 
they are retained on the outside of the serous cavity, where 
they may become strangulated, or affected with undue, if not 
fatal, inflammation. The operator should therefore never 
rest satisfied that the restoration has been accomplished unless 
he is convinced that the finger has been fairly within the 
abdomen, or in contact with the convoluted surface of the 
bowel. 

Penetrating wounds of the abdomen are rarely unattended 
with some protrusion of the omentum. From the situation of 
this serous lamella, and from the manner in which it is spread 



40 



Gross on Wounds of the Intestines. 



over the surface of the bowel, it is indeed usually forced 
out first, and not unfrequently it is the only part prolapseif. 
However this may be, it should always be carefully returned, 
otherwise the greatest mischief is to be apprehended. A dis- 
tinguished surgeon, Baron Larrey, has, it is true, advised 
us to let it alone, that is, neither to return it, nor to 
remove it by the knife or ligature; a practice recommended 
by some very eminent authorities. Soon after the accident, 
he observes, the extruded membrane swells, becomes thick 
and red, and assumes a rough, granulated aspect. These 
symptoms increase until the third day, after which they re- 
main stationary for nearly a fortnight, when the part begins 
to shrivel, and is ultimately reduced without any operation.* 
Very few practitioners will, I presume, be disposed to follow 
this advice, which is, to say the least of it, singularly at vari^ 
ance with that of the best writers on penetrating wounds of 
the abdomen and the management of ruptures. That prac- 
tice is undoubtedly the safest wiiich most readily promotes 
the recovery of the patient, and that this desirable end is more 
promptly and perfectly attained by returning the whole of 
the prolapsed omentum at once into the abdomen, than by 
allowing it to remain in the situation pointed out by the 
Baron, no one can doubt. Both experience and common 
sense are in favor of the course of treatment so long pursued 
by the ablest surgeons, and I can therefore see no necessity for 
adopting a new one, especially when that method is of an 
equivocal character. It is a good maxim in surgery, as it is 
in morals, to let well enough alone. 

It need hardly be remarked that, wlien the protruded parts 
are covered with dirt, faeces and blood, or other extraneous 
matter, they should be carefully cleansed before any attempt 
be made to restore them to their natural situation. The im- 
portance of this practice is too obvious to require any com- 
ment. The best article for this purpose is tepid water, either 



* Medico-Chir. Review, vol. ii, p. 261. 1821. 



Gross on Wounds of the Intestines. 



41 



alone or mixed with milk, applied by means of a sponge held 
some distance off. The stream thus produced is well calcula- 
ted to detach the foreign substances, whatever they may be, 
without inducing any additional irritation. In no case should 
the parts be sponged or wiped, for reasons which it is unne- 
cessary to specify. If the extraneous matter adhere with 
much firmness, it may be picked off with a pair of forceps, 
or some other instrument, and on no account should the 
bowel be replaced until it has been thoroughly cleansed. 

Fomenting the extruded parts with infusion of chamo- 
mile flowers, oil, hops, or wine and water, as recommended 
and practised by the late Baron Larrey, can do no good, and 
ought to be avoided. The advice of the French surgeon, in- 
deed, is decidedly objectionable, if not reprehensible. The 
abdominal organs are the best fomentors, and the sooner the 
protruded parts are brought into contact with them the 
better. 

The omentum, when prolapsed along with the bowel, 
should always be reduced last, and care taken to spread it 
out as much as possible over the parts which it naturally 
covers. This can generally be easily done by means of the 
index-finger of the right hand introduced into the peritoneal 
cavity, and is calculated to prevent its subsequent protrusion 
between the edges of the wound; a circumstance which 
almost constantly happens when this precaution is neglected. 

In regard to the management of the external wound, it is 
obvious that it must be conducted upon the same general 
principles as that of a solution of continuity in any other 
situation. Sutures should never be employed, except where 
they are imperiously indicated. It should be remem- 
bered that they are foreign bodies, which can never be 
resorted to without an increase of pain, or without endan- 
gering the development of too much morbid action. It is 
well-known, too, that when introduced into tendinous struc- 
tures they are apt to excite a bad form of inflammation, and 
that, if inserted into muscular parts, spasm and even convul- 
sions may be the consequence. Nevertheless, cases often do 

4 * 



42 



Gross on Wounds of the Intestines. 



occur in which we cannot dispense with them. The wound 
may be unusually large, or the patient so restless and unman- 
ageable as to render it impossible to prevent a recurrence of 
the protrusion unless the parts be sewed up. Under circum- 
stances such as these we would not only be warranted in 
employing the suture, but we should be justly culpable if we 
neglected it. Dogs bear this treatment with perfect impu- 
nity, and many cases are recorded in which it was advan- 
tageously employed in the human subject. In making a suture 
in this situation the needle should be carried through the lips 
of the wound within a line and a half or two lines of the 
peritoneum, and the requisite number of threads placed before 
any of them are tied, in order to avoid injury to the omen- 
tum. The ends are then cut off, and the approximation 
perfected by means of adhesive strips, the whole being 
secured by a compress and broad bandage carried two or 
three times round the abdomen. At the expiration of thirty- 
six or forty-eight hours the ligatures should be cut away, as 
the parts will have sufficiently united to render them unne- 
cessary. When the wound is very extensive some sur- 
geons prefer the quilled suture, as it is termed, but for this 
there can seldom be any necessity, when the case is managed 
in the manner just mentioned. 

Penetrating wounds of the abdomen, attended with lesion 
of the intestinal tube, constitute a class of injuries of a much 
more serious character than such as are accompanied merely 
by prolapse. The symptoms are generally more severe, 
there is more danger of peritoneal inflammation, and the 
treatment, especially when the opening is extensive, is alto- 
gether different; or, to speak more intelligibly, two wounds, 
involving different structures, exist, and consequently require 
different modes of management. 

When the inner wound is large the treatment to be em- 
ployed is sufficiently obvious, for no well educated surgeon 
would hesitate to resort at once to the suture, or to some other 
contrivance calculated to prevent frecal effusion. It is only 
where the opening is small that doubts seem to be entertained 



Gross on Wounds of the Intestines. 



43 



respecting the proper course to be pursued. The quesiion 
can only be decided by an appeal, not to the speculative 
views of professional men, but to direct experiment upon the 
inferior animals and observation upon the human subject. 
The evidence which I shall adduce will go far, if I mis- 
take not, to settle this important point of pathology and 
practice. 

Heister, who was confessedly one of the ablest anato- 
mists and surgeons of his day, expressly slates that all 
wounds of the intestines not exceeding the diameter of a 
goose-quill should be returned without stitching, which he 
asserts to be generally productive of severe pain, inflamma- 
tion, and other bad symptoms.* Dionis says if the opening 
is very small, as for example, when it is made by a bodkin or 
pen-knife, it is not necessary to sew it up; nature, seconded 
by a rigid diet, being fully competent to effect a cure.f To 
the same import very much is the testimony of Palfin,J and 
of Sabatier. The former of these authors observes that 
whenever the opening is diminutive it is not necessary to sew 
it up, but simply to return the part, and to restrict the patient 
to the smallest possible allowance of food, barely sufficient 
to prevent starvation. "If the wound," says Sabatier, "is 
very slight, as when only a few muscular fibres are involved, 
it is needless to resort to the suture, since a cure may be ac- 
complished without it." Sharp, in his Operations of Surgery,§ 
uses very nearly the same language. The opinion of Jobert, 
whose writings have been already several times quoted, is, 
that the wounded intestine may be safely returned, provided 
the opening does not exceed three lines. Where it is more 
extensive, as for instance half an inch, although reparation 
might possibly take place through the intervention of the 
epiploon, still there would be great danger of fa3cal effusion. 



* Travers, op. cit., p. 172. 

t A Course of Operations, p. 53. English Edition, London, 1733. 
I Anatomie Chirurg., T. ii, p. 76, 
!) P. 9. London, 1784. 



44 



Gross on Wounds of the Intestines. 



and hence he very justly concludes that it would be much 
belter to sew it up.* 

Richerand, also a modern writer, recommends a very differ- 
ent practice when the wound is very small, or does not exceed 
two or three lines. t His plan is to pass a loop of waxed thread 
through the mesentery, and to keep the inner wound as nearly 
as possible in apposition with the outer. The object is to 
afford a ready outlet to the feecai matter, by the artificial 
anus which is thus established. This method, to which I 
shall hereafter recur, is not new with Richerand, but origina- 
ted long ago with La Peyronie, an old French surgeon. Boyer 
remarks^ that when the wound is more than four lines in 
extent enteroraphy becomes indispensable. 

In a preceding part of this essay — page 8 — several expe- 
riments are related which have a direct bearing on this sub- 
ject. The particulars, however, it is not necessary to repro- 
duce in this place. It will be sufficient to say that in the 
three experiments in which the wound did not exceed four 
lines, or the third of an inch, the animals promptly recovered, 
while in the remainder, five in number, and in which the 
opening was of greater extent, they all died of faecal 
effusion. So far, then as these researches go, they tend to 
confirm the opinion of Heister, Sharp, Garangeot, and oth- 
ers, that a protruded bowel, in which there is only a very 
small wound, may be safely returned into the abdomen, 
without any apprehension of the escape of alvine matter. 
But would the surgeon be really justified in pursuing such 
a practice? I unhesitatingly aver that he would not, for 
the reason that, although this course may, in the gene- 
rality of eases, be attended with success, yet it is liable 
to occasional failure, and should therefore be discountenanc- 
ed. The introduction of a suture, which is all that can 



» Maladies du Canal Intestinal, T. i, p. 72. 

fNosographie et Therapeutique Cliirurg., T.iii, p. 819. Paris, 1821. 
t Traitc des Maladies Chirurgicales, T. vii, p. 377. Paris, 1831. 



Gross 071 Wounds of the Intestines. 45 

be needed in a small wound, wiU assuredly add little either 
to the present suffering of the patient or to the danger of 
peritoneal inflammation; the operation is neither painful nor 
tedious, and, what is of far more consequence, always, 
when well performed, protects the individual from faecal 
effusion. In several of my experiments death was produced, 
not from any undue injury inflicted upon the bowel from 
stitching or any rough manipulation, but from the interval 
between the sutures being so great as to prevent the perfect 
closure of the wound; a fact which should never be lost 
sight of in the management of a lesion of this kind. When- 
ever the contact is incomplete, the mucous membrane be- 
comes everted, and interferes with the adhesive process. The 
more accurately this is obviated the less risk will there 
be of the escape of fseculent and other matter, calculated to 
induce fatal peritonitis. I do not care, therefore, how small 
the wound may be, if it is only a line and a half, or two lines 
in extent, it should by all means be sewed up. In this prac- 
tice alone can there be perfect security for the patient. The 
villous membrane may, it is true, effect a temporary closure 
of the wound, but there is always danger that before adhesion 
can take place, the part will become so much relaxed as to 
lead to mischief. 

In closing this branch of the present inquiry I cannot omit 
quoting the sentiments of an old and distinguished surgeon, 
whose works, highly popular in their day, have been too much 
neglected by modern practitioners. I allude to IMr. Benja- 
min Bell.* "However small," saj-s he, "a wound of the 
intestine may be, it ought always to be secured with a liga- 
ture; for although it is alleged by some that we should rather 
trust to nature for the cure of a small opening than to insert 
a ligature, to me it appears that the opinion is by no means 
well-founded; insomuch that I would not leave even the 
smallest opening that could admit either faeces or chyle to 



* A System of Surgery, vol. v, p. 281. 



46 



Gross on Wounds of the Intestines. 



pass, without stitching it up. Much danger may ensue from 
omitting it; and the hazard of the patient cannot be increased 
by the practice being adopted.'' 

Co-incident with this opinion of Mr. Bell is that of Mr. 
Lawrence, of London, whose views upon the subject are 
entitled to great weight, from the unusual opportunities which 
he has enjoyed for treating strangulated hernia. Adverting to 
the practice recommended by Jobert, and referred to in a pre- 
vious paragraph, of replacing the bowel without suture, when 
the wound does not exceed three lines, he affirms that such a 
procedure would not only be hazardous, but unwarrantable 
in the present state of the science. "In case of such an 
opening in the intestine," says he, "I should employ suture; 
not considering it safe to return the bowel into the abdomen 
without this precaution."* 

It might be supposed that, in a treatise professedly devoted 
to the subject, considerable space would be alloted to the 
therapeutic treatment of wounds of the intestinal canal. Such 
a course would undoubtedly be highly proper, if not, indeed, 
indispensable, if these lesions involved any thing peculiar in 
this respect; but when it is remembered that they are to be 
managed upon the same principles as wounds in other parts 
of the body, much discussion of this kind would, to say the 
least of it, be irrelevant. 

After the bowel has been restored to its natural situation, 
whether enteroraphy has been employed or not, the first and 
most important object is to guard against the occurrence of 
peritoneal inflammation, as it is upon this that the safety of 
the case mainly depends. Perfect quietude in the recumbent 
posture, the early and copious abstraction of blood, especially 
if the patient be plethoric, or the wound extensive, and the 
most rigid observance of the antiphlogistic regimen, are the 
means upon which our reliance is to be placed in the first 
instance. If the bowels be not evacuated spontaneously in 



* Treatise on Ruptures, p 301. London, 1838. 



Gross on Wounds of the Intestines. 



47 



six or eight hours after the parts have been returned, a stimu- 
lating enema should be thrown into the rectum, but under 
no circumstances should the alimentary canal be disturbed 
by the administration of purgative medicines by the mouth, 
as these, however mild, will be likely to cause griping pains 
and to interfere with the reparative process. This plan is to 
be persisted in for at least three or four days, when a dose of 
castor oil may be given, or, which would be better, an 
ounce of sulphate of magnesia or soda. The more fluid the 
alvine matters can be rendered the less likely will they be to 
be arrested at the affected part, to derange the sutures, or to 
disturb the healing process. All drastic articles must be sedu- 
lously avoided, on account of their tendency to create gastric 
irritation, and to excite undue peristaltic action of the bow- 
els; two circumstances concerning which we cannot be two 
much on our guard. 

The pulse should be attentively watched, and as soon as 
re-action is fully established, blood must be taken from the 
arm by a large orifice, and while the patient is in the 
serai-erect posture. The amount to be abstracted must 
vary according to the indications of the case, particularly the 
age and constitution of the individual, the return, continu- 
ance, or increase of the local pain, the force and frequency 
of the pulse, and the extent of the injury. The first bleeding 
ought, in general, to be tolerably copious, but after this 
eight or ten ounces at each repetition will be sufficient. 
In this way we prevent inflammatory action, or moderate 
it, where it has already taken place, without inducing 
too much prostration. It should be recollected that the 
pulse in peritonitis is hard, wiry, and contracted, and that 
the practitioner, if he be not fully aware of this, will be 
apt to fall into the error of omitting the abstraction of 
blood at a period when it is loudly called for, and when it 
can alone be of any avail in arresting the progress of the 
malady. General bleeding, however, is not always admissi- 
ble. The shock which the system has received may be 
unusually severe; the reaction may be tardy and imperfect; 



48 



Gross on Wounds of the Intestines, 



and the patient may perhaps be for several days in a do- 
sing state, with a weak and tremulous pulse, cold extremi- 
ties, and great pallor of the countenance. In such a case, 
instead of taking blood from the arm, the practitioner must 
content himself with fomentations to the abdomen, consisting 
simply of warm water, or of water in which hops, opium, or 
poppy-heads have been infused, and frequently renewed. Even 
leeches are scarcely to be thought of. Where the stomach is 
irritable, mustard poultices are to be applied to the epigastric 
region, and if the patient is unable, as he occasionally is, to 
void his urine, it must be drawn off with the catheter. If 
cough be present, it is to be combated by the usual means, 
and not allowed to progress, as the concussion thus induced 
might prove highly detrimental. When the patient is haras- 
sed with colicky pains, relief may be attempted by laudanum 
or the salts of morphia, but as the effect of these and similar 
articles is to create constipation, they should be employed as 
sparingly cis possible. The tenesmus which is sometimes 
present is to be allayed by anodyne injections or supposito- 
ries; and where there is much discharge of blood from the bow- 
els, the acetate of lead may be administered in large and 
repeated doses. 

When there is much tumefaction of the abdomen with gas- 
tric irritability, and tenderness on pressure. Baron Larrey* 
advises cupping, aided by camphorated and oily embroca- 
tions, emollient cataplasms, and anodyne enemeta. In a 
case, apparently of the most hopeless character, in which thjp 
practice was put in force, the disease yielded in a very short 
time, not, however, without vesication of the whole surface 
of the abdomen. With cupping I have no experience in the 
treatment of peritoneal inflammation, traumatic, or otherwise; 
but it seems to me that it would be attended with so much 
suffering to the patient as to preclude its employment in 



• Surgical Essays, translated by Dr. Revere, p. 235. 



Gross on Wounds of the Intestines. 



49 



most, if not all cases of the kind. Leeching would certainly 
be preferable. 

The diet must be of the most simple nature. For the first 
fortnight or three weeks, it should consist chiefly of amylace- 
ous articles, as arrow root, tapioca or sago; afterwards it may 
be more nutritious, but must still be fluid. Solid, stimu- 
lating, or flatulent food is not to be used for several months after 
tlie accident. Two or three cases will hereafter be men- 
tioned, where, from disregard of this precaution, the patient 
fell a victim to his imprudence, when he was apparently out 
of all danger. As a constant drink, nothing can be better 
than cold water, flax-seed tea, slippery-elm water, or a solu- 
tion of gum-arabic, simple or acidulated. In a word, the 
patient should be half-starved, and as much depleted as is 
consistent with the restorative process. Our treatment must 
be prompt and energetic. No time is to be lost, or the case 
will slip out of our hands. The great error with most prac- 
titioners is that they do not abstract blood sufficiently early, 
or before peritoneal inflammation is thoroughly established, 
or has made such inroads upon the system as to render it 
impossible to arrest its progress. 

When blood is extravasated in considerable quantity into 
the peritoneal sac, as is evinced by the soft and tremulous 
state of the pulse, the pallor of the countenance, the coldness 
of the extremities, and the constant disposition to swooning, 
the patient must be immediately placed in the recumbent 
posture, and made to take large and frequently repeated 
doses of the acetate of lead in union with opium. Mustard 
poultices should be applied to the hands and feet, and cloths, 
wrung out of cold water, to the abdomen, which is to be encir- 
cled at the same time with a broad bandage, to afford equa- 
ble support to the viscera, and thereby promote the coagula- 
tion of the effused fluid. When there is reason to suspect 
that a large artery has been opened, the most effectual prac- 
tice will be to cut down upon the parts, and secure it with a 
ligature. This procedure, however, has few advocates, and 
should only be employed as a dernier resort, not as a 
5 



50 



Gross on Wounds of the Intestines. 



matter of choice. It would certainly be better to make an 
effort to save the patient by an operation, even of a desperate 
character, than to allow him to perish from the loss of blood, 
when the wounded vessel is within our reach. 

The dressings must be light, simple, and unirritating. If 
there be a discharge of fecculent matter, as there may be when 
the internal wound has not been properly sewed up, or even 
where there has been no protrusion in the first instance, it should 
be disturbed as little as possible, until there is reason to be- 
lieve that the bowel has contracted firm adhesions to the 
surrounding parts. By disregarding this precaution fatal 
effects might ensue from the extravasation of the matter into 
the peritoneal cavity. During the whole treatment the utmost 
attention should be paid to cleanliness. As the external 
opening diminishes, means are to be employed to prevent the 
escape of feces, by which the patient will be rendered more 
comfortable, and the healing process expedited. 

When the patient is well enough to sit up or walk about, 
the weakened parts should be supported by a compress and 
broad bandage, or, what is better, a good truss, which should 
be worn day and night, to prevent the separation of the edges 
of the sore, and the protrusion of the contents of the abdomen. 
This caution, as has been justly observed by Mr. Benjamin 
Bell, ought to be persisted in for a considerable time after the 
cure has been completed. By a want of attention to this 
point, very troublesome cases of hernia have occurred, which 
might otherwise have been obviated. 

Patients who have recovered from wounds of. this kind 
nxust pay particular attention to their bowels, which should 
be kept in a soluble condition, and on no account be allowed 
to be costive, even for a single day. They should also be 
extremely temperate in their diet, and carefully masticate 
their food before it is swallowed. All rough exercise, as 
riding on horse-back, jumping, running, and even rapid walk- 
ing, must be avoided. 

(To be continued.) 



Selecttous from American auti iForetgn Journals. 



Virei/s Objections to Liebig's Theory of the Uses of Respi- 
ration and of the Food. — Liebig maintains that the chief use 
of the food is to supply carbon and hydrogen, which, uniting 
with the oxygen absorbed from the air, give rise to the gene- 
ration of animal heat. He consequently holds that there is a 
certain fixed relation between the amount of food consumed, 
and the quantity of carbon and hydrogen thrown off at the 
lungs. Mr. Virey opposes this theory, as contrary to com- 
mon observations, as, even though it be allowed to be appli- 
cable to mammalia, birds, and reptiles, it is by no means to 
those animals which respire by m.eans of branchias. Thus all 
animals with branchiae consume but little oxygen, compara- 
tively speaking, and yet many of them devour very great quan- 
tities of food. Even the largest and most voracious of the 
reptiles, as the alligators, crocodiles, &c., which devour enor- 
mous quantities of food, under a burning climate too, respire 
feebly with their vesicular lungs, and consume but little oxy- 
gen. 

Fishes, whose blood is but imperfectly oxygenated by the 
branchial apparatus, are perhaps among the most voracious of 
animals, and yet, according to Liebig's theory, they ought to 
eat little, because they consume little oxygen. 

The same holds true of the Mollusca. The cuttle-fish, 
buccinum, stronibus, murex, &c., grow to a large size; but 
their respiration is very imperfect, and yet they are great flesh- 
eaters. The Crustacea, again, as the crabs, lobsters, &c., 
grow rapidly, because they are great eaters; but their bran- 
chial apparatus is not fitted to consume much oxygen. 

In all these animals assimilation takes place very rapidly, 
notwithstanding their feeble respiratory powers; and they are, 
besides, by no means deficient in activity or muscular pow- 
ers, though their flesh be but feebly azotized or animalized, 
and their blood is always cold. 



52 



Phloridine. 



If it be one of the characters of vitality, that the more per- 
fect this principle is, the greater is the number of germs, or 
eggs, or foetuses produced, then, quite contrary to Liebig's 
theory, the number of germs produced is in the inverse ratio 
of the perfection of the respiratory functions. Fishes and 
mollusca deposit their spawn or eggs by millions; but the 
mammalia, and even the birds, whose respiratory functions 
are the most perfect, are in this respect infinitely behind these. 
On the other hand, it is seen that the number of germs or 
eggs is rather proportioned to the nutrition received; for the 
amount of food taken is not proportioned to the respiration in 
the animal kingdom. 

Virey therefore concludes, that the vital force or central 
nervous energy has more to do with the production of animal 
heat than the consumption of carbon at the lungs, and this 
for three special reasons; — 1st, Because a fecundated egg 
resists a freezing temperature longer than one which has not 
been fecundated. 2d, That a hybernating insect, reptile, or 
animal, or even trees during winter, by the sole influence of 
a vital power, resist a freezing temperature, whereas the sam& 
animals, if dead, would be instantly frozen. 3d, That many 
mammalia and birds keep themselves warm even in the most 
rigorous winters under the Pole, not in consequence of a great- 
er amount of oxygen consumed, nor by a greater amount of 
muscular activity, but in consequence of a more abundant 
highly azotized or animalized nourishment. — Jour, de Pharm., 
May, 1842. 



Phloridine. — This is a new medicine, which is now very 
highly spoken of by French practitioners as a useful adjunct 
to our cinchona preparations. It has been used for some 
years in Germany, Poland, and France. It is extracted from 
the bark of the roots of the apple-tree and the wild cherry-tree, 
and is thus prepared: the bark of recent roots is boiled with 
\vater sufficient to cover them, for half an hour. This is 
poured off, and the same quantity is again used; these two 
fluids are mixed together, and at the end of six hours deposit 
the phloridine in the form of a deep-red velvety-looking matter. 

Lebaudy, the editor of the Journal des Connaissances 
Medico- Chirurgicales, says, "its efficacy is so decided, that 
we cannot hesitate to class it with the most powerful febrifu- 
ges; and it has this advantage over quinine, that it never iudu- 
ces gastralgia." — Braithivaite's Retrospect, No. 5. 



Treatment of Hemorrhagic Diathesis. 



53 



Treatment of the Hemorrhagic Diathesis. — The London 
and Edinburgh Monthly Joiirnal of Medical Science for 
July last contains an exceedingly interesting paper on this 
subject, read before the Medico-Chirurgical Society of Edin- 
burgh, by James Miller, the successor of Sir Charles Bell, in 
the Surgical chair of the University of Edinburgh. 

To constitute the hemorrhagic diathesis, we have not only, 
iVIr. Miller observes, the blood flowing through dilated and 
uon-contractile tubes, but sent thither in greater volume than 
in ordinary and healthy circumstances, thinner and more 
fluent than in health, and little if at all able to arrest its own 
course by assuming the solid form. In addition, the capillary 
tunics are not only thin, but weak, and easily lacerable; a 
slight bruise produces serious ecchymosis; coughing may 
induce haemoptysis; a sneeze brings on epistaxis; diarrhoea 
occasions copious evacuations of blood by the rectum; and 
extravasations are not unlikely to follow but slight causes 
within internal cavities. The whole circulating system, be- 
sides, is usually in an irritable and excited condition; the 
pulse being considerably above the healthy standard, and the 
heart acting with unusual force and sharpness. Not unfre- 
quently.a febrile condition at the same time exists; and when 
it does exist, it increases the intensity of the diathesis. 

In the treatment of the hemorrhagic diathesis, Mr. M. 
directs attention to the following points: — 1. Energetic treat- 
ment at the outset, for then only have we the blood favorable 
for coagulation, and the parts tolerant of pressure. 2. The 
propriety of internal remedies — astringents, sedatives, nause- 
ants, and hydragogues — to obviate, if possible, the morbid 
condition of the blood; and administered either by the mouth 
or anus, according to circumstances. 3. Abandonment of 
escharotics — especially of the actual cautery, being at the best 
only occasionally and temporarily beneficial, and ultimately 
highly pernicious. 4. Pressure, preceded by a styptic, early, 
accurately, uniformly, and yet moderately applied, the best 
local means of treatment. 5. Irritants and cupping, at 
some distance from the bleeding point, not unlikely to prove 
beneficial; the former by creating an inflammation in a com- 
paratively unimportant part, and thereby increasin? the 
amount of fibrin in the general mass of blood; the latter by 
averting the sanguineous determination to the source of hem- 
orrhage. 6. Careful avoidance of simply febrile accession, 
which would have the effect of exciting the circulation, at the 
same time diminishing still further the amount of fibrin. 
7. Patient persistence in the foregoing system, without abrupt 



5 i Deafness cured by Morphia — On Percussion. 



or frequent change of remedies. 8. In protracted cases, 
nutritious, yet non-stimulating diet. 9. Failing ordinary 
means, transfusion is to be attempted. 10. The question of 
projphijlaxis , not irrational; the tendency being once known, 
its removal ought at least to be attempted. 



Deafness cured by the endermic use of Morphia. — Dr. 
HoEBEKE relates in the Archives de Med. Beige, the follow- 
ing case of deafness, the cure of which he ascribes to the 
endermic use of morphia. A lady liad become so deaf after 
an attack of fever that she could not distinguish a word, unless 
it was bawled into her ear by applying the mouth close to it. 
But along with the deafness there was always an incessant 
noise in the ears — at one time like the hissing of boiling 
water, at other times like the roaring of a hundred voices 
together — which was often so distressing as to cause headache 
and confusion of ideas: — these feelings were always worse 
when the head was on the pillow. There was a quantity of 
wax in the ears; but no relief was obtained when it was re- 
moved. Nothing irregular could be perceived either in the 
ears themselves or in the throat. Leeches were applied 
behind the ears, and emetics and purgatives given; but no 
relief followed. Supposing that the symptoms might be 
dependent upon some anomalous state of the nervous appa- 
ratus, a blister was applied behind each ear, and the excoria- 
ted surface was sprinkled with half a grain of sulphate of 
morphia. By the next day the noise and deafness on the left 
side had quite ceased, and on the right were much abated: — 
the headache, too, had disappeared. 

As the unpleasant feelings still continued on the right side, 
a second blister was applied and treated in the same manner 
as before, with morphia: — the success was decided, and the 
patient was quite freed of all her annoyances. 

[We opine the blistering had quite as much to do with the 
cure as the morphia.] — American Journal of Med. Sa. 



On Percussion. — By John Hughes Bk^-nett. Mediate 
percussion as employed by Piorry, is undoubtedly a more 
valuable means of diagnosis than is generally allowed. His 
experience, it is said, enables him to "map out, as it were, on 
the surface of the skin, with ink. the size and form of the 
heart, arch of the aorta, liver, spleen, kidney, &c.; and indi- 



On Percussion. 



55 



cate to the eighth of an inch, the exact height of pleuritic 
effusion, or the margin of circumscribed pneumonic dulness." 
At first sight this partakes too much of the marvellous, but 
when we know the length of time he takes to percuss a single 
patient, (half an hour,) we may suppose him to be a more 
expert operator than the generality of practitioners. The in- 
struments he uses are, 1st. The Hammer: the head of which 
is made of steel, brass, or iron; a capsule is screwed to the 
end with a projecting disc of caoutchouc; the handle is 
made of wood, with depressions for the fingers and thumb. 
The head of the handle is not placed exactly at right angles 
with the handle, but has a slight obliquity upwards. "This 
is necessary, because in employing it the handle is almost 
certain to be somewhat elevated, and this slight obliquity 
even then allows the practitioner to strike the pleximeter per- 
pendicularly." 2d. The Pleximeter: made of ivory, wood, 
or metal, with a handle at each extremity, to enable the prac- 
titioner to take hold of it more readily. 

General rules to he followed in the practice of Mediate 
Percussion. — 1. The pleximeter should be held by the pro- 
jecting handles between the thumb and index finger of the 
left hand, and pressed firmly down upon the organ to be per- 
cussed. Much depends upon this rule being followed, as the 
sound and sense of resistance are considerably modified 
according to the pressure made by the pleximeter. A very 
easy experiment will prove this. If, for instance, the plexi- 
meter be struck while it rests lightly on the abdomen over the 
umbilicus, and again, when it is pressed firmly down amongst 
the viscera, the change in tone will be at once perceived, in 
the first case a sound is produced, from the muscles and in- 
teguments being alone influenced by the force of the blow; in 
the second case, a clear tympanitic sound is occasioned from 
the vibration of the walls of the intestine. In every instance, 
therefore, the pleximeter should be so held and pressed down, 
as to render it, so to speak, a part of the organ we wish to 
percuss. 

2. Care must be taken to strike the pleximeter fairly and 
perpendicularly. Unless this be done, vibrations are com- 
municated to textures in the neighborhood of the organ to be 
percussed, and fallacious results are the consequence. If, in 
percussing the lungs, for example, the blow be made obliquely, 
we obtain the dull sound produced by the rib, and I have seen 
considerable error in the diagnosis thus occasioned. 

3. A strong or gentle stroke with the hammer will modify 
the tone and sense of resistance, inasmuch as the impulse 



56 



On Percussion. 



may be communicated by one or the other to a deep-seated or 
a superficial organ. Thus a gentle stroke will elicit a pulmo- 
nal tympanitic sound just below the fourth rib, where a thin 
layer of lung covers the liver, but a strong one will cause a 
jecoral parenchymatous sound. At the inferior margin of the 
liver, on the other hand, where a thin layer of the organ cov- 
ers the intestines, the reverse of this takes place, a gentle 
stroke occasioning a dull, and a strong one a clear sound. 

4. By withdrawing the hammer immediately after the blow, 
we are better able to judge of the sound; by allowing it to 
remain a moment, we can judge better of the sense of resis- 
tance. 

5. The integuments should not be stretched over the part 
percussed, as when the stethoscope is employed, for an unnat- 
ural degree of resistance is thus communicated to the hand of 
the operator from the muscular tension. In every case, espe- 
cially where the abdomen is examined, the integuments and 
superficial muscles should be rendered as flaccid as possible. 

6. It is always best to percuss on the naked skin. It is not 
absolutely essential, however, and in cases where, from mo- 
tives of delicacy, it is desirable that the chest or abdomen be 
not exposed, it only becomes necessary that the covering of 
linen or flannel be of equal thickness throughout, and not 
thrown into folds. 

Special rules lo be followed in percussing Ihe chesf. — Per- 
cussion of the lungs generally bears reference to a change in 
density, which is only to be detected by cornjjaring the heal- 
thy with the morbid portions. The great practical rule here 
to be followed, is to apply the pleximeter to both sides of the 
chest in succession, with the same firmness, exactly in the 
same situation, and let the blow with the hammer be given 
with the same force. Care must be taken that the position of 
both arms be alike, as the contraction of the pectoral muscles 
on one side more than on the other may induce error. In 
short, every circumstance must be the same before it is possi- 
ble to determine in delicate cases, either from the tone or 
sense of resistance, whether change of density exist in the 
lungs. When circumscribed alterations are discovered in the 
pulmonary tissue, their limits may be marked out on the sur- 
face of the skin, in the manner jireviously indicated. In this 
way, I have frequently succeeded in determining with accu- 
racy the size and form of circumscribed indurations, arising 
from partial pneumonia and pulmonary apoplexy. Under the 
clavicles, the pleximeter must be applied with great firmness. 
Inferiorly, a thin layer of lung lies over the superior surface 



On Percussion. 



57 



of the liver; and to determine the exact place where its infe- 
rior border terminates, the blows with the hammer should be 
very slight. Posteriorly, also, the pleximeter must be firmly 
applied, and the force of the blows considerable: but they 
should decrease in force inferiorly, where a thin layer of lung 
descends over the liver much deeper than anteriorly. 

In a healthy state, a distinct difference may be observed in 
the sonoriety of the lungs immediately after a full expiration 
and a full inspiration. This does not take place when the 
tissue becomes indurated from any cause; and thus we are 
furnished with a valuable diagnostic sign. Congestion of the 
lung, and pneumonia in its first stage, causes only slight dul- 
ness and increased resistance, which, however, are readily 
detected by the practised percussor. In the second and third 
stage of pneumonia, and in apoplexy of the lung, this dulness 
and resistance are well marked, and even an impression of 
hardness and solidity communicated to the hand. AVhen, 
however, the lung is studded with tubercles, the induration is 
most intense, and the greatest degree of resistance communi- 
cated. 

Partial induration from pneumonia, apoplexy, or tubercular 
deposition, may be detected by percussion, even when deep- 
seated and covered by healthy portions of the lungs. In this 
case, by pressing with the pleximeter, and striking lightly, a 
tympanitic sound is only heard; but by pressing the plexime- 
ter down firmly, and striking with force, the dull sound may 
be elicited and circumscribed. When induration, however, 
exists inferiorly in those portions of the lungs which overlap 
the liver, it requires great practice to detect them with cer- 
tainty. Caverns in the lungs, when large and filled with air, 
induce a tympanitic sound; but they are generally more or 
less full of viscous and fluid matters, and give rise to dul- 
ness. 

Two or three ounces of fluid may be detected in the pleu- 
ral cavity, by causing the patient to sit up. It is readily dis- 
tinguished posteriorly, from the dulness of the liver on the 
right side; on the left, however, the limit between it and the 
spleen is not so well marked. The height or level of the 
fluid is readily determined, and should be marked daily by a 
line made with nitrate of silver. If the etfusion be only on 
one side, the peculiar humoral dulness is more easily detected. 
It disappears on placing the patient in such a position as will 
cause the fluid to accumulate in another part of the pleural 
cavity, when the space, which was previously dull, becomes 
clear, AVhen the etfusion entirely fills the pleural cavity, no 



58 



Remedy for Scalds and Burns. 



limit of course can be detected; but, even then, the dulness 
is distinguished from that of the liver by the diminished feel- 
ing of resistance. 

When air is effused into the pleura, the sound is like that 
of a drum, and readily detected. — Braithwaite's Retrospect. 



New Remedy for Scalds and Burns. — Mr. Wm. Rhind 
recommends as a remedy for burns and scalds, a solution of 
gum-arabic, repeated coats of it being appHed, so as to form 
a complete covering to the injured parts. He relates several 
cases in which he tried it, and states that in all relief was 
procured in a very short time. The more recent the case, 
however, the more speedy was the removal of the pain. In 
those cases where blisters had appeared they were opened, 
and the solution applied; very frequently the application of 
the solution prevented the effusion of more serum; in some 
cases, however, serum was again effused and again evacua- 
ted. 

In those distressing cases of the extensive burning of the 
bodies of young children, Mr. R. states that he would not 
hesitate applying the solution over the whole body, at about 
the warmth of 96°. It does not cool down the system (he 
remarks) by sudden evaporation or sudden abstraction of heat, 
like a common cold fluid, a circumstance in most cases to be 
dreaded, for gum is a bad conductor ol' heat; neither does it 
preclude an exposure to moderately cool air, which seems to 
keep down the excessive irritation consequent upon extensive 
scalding of the skin. 

As it is of consequence to have the solution prepared in- 
stantly, the powdered gum, if it can he procured, may be in 
a few minutes dissolved in warm water. If this is not ready 
prepared, the common gum in small particles roughly pound- 
ed, will very soon dissolve, and the application in any case 
may be applied at a temperature of 90° or 100°, although in 
general it is more soothing when applied colder. Rancid 
gum solution should not be used, as it in this state has lost its 
adhesive quality. Two, three, or four applications may be 
necessary at intervals of five or ten minutes. The skin should 
be previously freed of all oily mattters, and the first coating, 
in order that it may be insinuated closely into the furrowed 
surfaces of the skin, should be rather thinner than the subse- 
quent ones. In order to produce the proper efiect it should 



Menstrual Fluid — Microscopic AnimalculcB. 59 



form a varnished coat of some thickness and closeness over 
the whole space of the burnt part. — Edinburgh Med. and 
Surg. Journ. Oct., 1842. 



Analysis of the Menstrual Fluid. — BoucHAitDAT undertook 
a new analysis of the menstrual fluid, obtained from a female, 
who consented to allow a speculum to remain in her vagina 
for ten hours, in order that an ounce of it might be procured. 
Without this precaution the fluid becomes mixed with vagi- 
nal mucus and urine, as the presence of ammoniaco-magne- 
sian phosphate proves. The following is the analysis: water, 
90.S; fixed matters, 6.92. The fixed matters were thus com- 
posed; fibrine, albumen, and colouring matter, 75.27; extrac- 
tive matter, 0.42; fatty matter, 2.21; salts, 5.31; mucus, 16.79. 
The female from whom the secretion was obtained was a 
patient of Boismont's, and he considers the great pro- 
portion of water due to the delicacy of her frame, and her 
subsisting chiefly on a vegetable diet. Another specimen of 
menstrual fluid, examined by Donne, gave the following 
microscopic characters: 1st, abundance of the ordinary glo- 
bules of the blood; 2d, vaginal mucus formed of epidermic 
squania3 from the mucous membrane of the vagina; 3d, mu- 
cous globules furnished by the neck of the uterus. From 
these examinations it results that the menstrual fluid does not 
differ from arterial blood. As to the acid or alkaline nature 
of the fluid, observed by authors, it depends upon the pre- 
sence of mucus from the vagina and neck of the uterus. This 
mucus, as Nauche has proved, is acid in a healthy woman 
and after delivery, but becomes alkaline when it is glairous, 
or the product of inflammation; if only a limited portion of 
the passage be affected, the secretion will be acid in one part 
and alkaline in another. — Provi. Med. Journ., July 30, 1842. 



Revivification of Microscopic Animalcul<x. — Milne Edwards 
read a report on a memoir of Doyere on this subject. 

It is well known that when a few drops of water are 
sprinkled on moss which has been kept dry for months or 
years, certain microscopic animalcule make their appear- 
ance; but it has not been decided whether these little animals 
are really brought to life again, or whether their ova had not 



60 



Corpora Lutea. 



remained concealed in the moss, and were afterwards vivi- 
fied. 

Doyere has found that, with the assistance of the micro- 
scope, we can discover in the dried sand of rain-spouts a 
number of small bodies, which closely resemble the remains 
of these animalculae, deformed through the effects of dessica- 
tion. The author has taken these remains, carefully dried 
them on glass plates, and found that they were afterwards 
capable of being restored to life. On pushing his experi- 
ments further, the author found that, on applying heat at 
145° or 150* Fahrenheit, the animalculfe were destroyed, and 
it was impossible to bring them to life again. But when they 
were previously dried, and all the moisture which they natu- 
rally contain was gradually expelled, they resisted a very 
great degree of heat; in some experiments the heat was car- 
ried to 120° C, and the animalculse afterwards restored to 
life.— Proy. Med. Journ., Aug. 37, 1842. 



Corpora Lutea. — Dr. Wm. Davidson of Edinburgh, gives 
an account of three dissections of females, neither of whom 
was pregnant, and in each of which, corpora lutea were 
found. They had all the characters assigned to them by Dr. 
Montgomery; a central cavity or fibrous coagulum; an oval 
form, and a radiated white cicatrix in the centre, just about 
tha central body; the body being at the same time immedi- 
ately under the peritoneal coat. This last is much insisted 
upon by Robert Lee, as he avers that "false corpora lutea are 
never observed in immediate connection with the peritoneum, 
a small portion of stroma intervening." As to the females, 
the first had been in a weakly state for some years, during 
which time she had no children. The second was unmarried, 
and had menstruated three days previous to her death. There 
was no history of the third case, but all the organs were 
healthy and the fallopian tube and uterus were in every way 
natural. Dr. Davidson expresses his confident opinion, that in 
none of these cases had there been impregnation previous to 
the appearance of these bodies. He refers to Professors Alli- 
son, Allen Thomson, John Reid, and Mr. Goodsir, in proof of 
the correctness of his statement, and of their perfect resem- 
blance to a true corpus luteum. 

Dr. Davidson, as the result of his investgations, says, "I am 
led to believe, that impregnation cannot take place without the 



Signs of Maturity in new-born Chiklrcn. 61 

appearance of a true corpus hiteum, but that a true corpus 
luteum may appear independent of impregnation." — Lond. ^- 
Edin. Month. Med. Journ. Dec. 1S41. 



Signs of Maturity in neiv-born Childi'en. — According to 
Cliaus&ier, if a mature child be measured immediately after 
birth, the middle of its length will be exactly at the navel, or 
a very little below. It is, however, doubtful whether this 
happens in all cases; and Mende has impugned its general 
accuracy. The following are some results noticed by Mr. 
Taylor, Lecturer on Medical Jurisprudence at Guy's Hospital, 
and Dr. Geoghegan, Professor of Med. Jurisp. in the Royal 
College of Surgeons in Ireland. 

Case. Whole length. Attachment of the Umbilical Cord. 



1. 


m 


a quarter of an inch below the centre. 


2. 


20 


half an inch " " *' 


3. 


ITA 


half an inch nearly " " 


4. 


16A 


iialf an inch " " 


5. 


19 


half an inch " " 


6. 


17 


a little below " " 


7. 


18 


exactly at the centre. 


8. 


17 


exactly at the centre. 


9. 


203 


a little below. 


10. 


m 


a little below. 


11. 


m 


exactly at the centre. 



Guy's Hospital Reports, April, 1842. 



On a peculiar affection of the Cornea in Nicrses. By Prof. 
Nasse. — A malignant form of keratitis or inflammation of the 
cornea occasionally accompanies puerperal attacks, and in 
general terminates fatally. This allection, however, is not of 
a malignant nature, and appears at any time during the whole 
period of nursing, from a month after delivery to a year and 
a half, if the child be suckled so long. The eye is felt irrita- 
ble and the conjunctiva is seen injected Avilh blood. Occa- 
sionally catarrhal symptoms attend the complaint, at other 
times little vesicles appear over the surface ol the con- 
junctiva. Sometimes rheumatic symptoms are present, at 
other times it comes on with a vesicular cutaneous eruption 
over the face. The conjunctival inflammation rapidly passes 
to the cornea and is accompanied by the usual darting pains 
6 



6*2 Peculiar affection of the Cornea in Nurses. 



in the eye and margin of the orbit. From the third to the 
eighth day an abscess forms within the layers of the cornea, 
when the intlammatory symptoms diminish, and if nothing be 
done to put an end to the complaint, it bursts into the ante- 
rior chamber and occasions hypopion. 

The disease is not peculiar to any age, constitution, or sea- 
son; but is in every case preceded by great lassitude, debility, 
and leanness, brought on by excessive lactation, in fact, seems 
to be a disease of debility. Blood-letting is consequently 
never indicated, but blisters behind the ears, diaphoretics 
combined with bitter infusions, quinine and sulphuric acid, a 
tonic diet, and above all, the giving up suckling the child, 
generally effect a cure in about three weeks. It is mentioned 
that the separation of the child is the most important part of 
the treatment; and cases are related where the child being 
allowed to suckle before the cure was completed, brought it 
back with increased severity, and could not be stopped till the 
child was again removed, when the disease rapidly gave 
way. — Edin. Med. and Surg. Journ., July, 1842. 



THE WESTERN JOURNAL. 



Vol. VII.— No. I. 



LOUISVILLE, JANUARY 1, 1843. 



WESTEHN METEOEOLOGY. 

While engaged, last summer, in a Medical survey of the valley 
of the Lakes, we made a visit to the Western Reserve College in 
the village of Hudson, Ohio, and became acquainted with Professor 
Loomis. This gentleman is already known to such of our readers 
as cultivate the science of Meteorology, one of the most charming 
and useful of the various haninaids of Medicine. But we fear, 
that the number who have enlisted her into their service, is not great. 
Would that we could augment it — could impress upon all, the mani- 
fold advantages they could derive, in their aetiological inquiries, 
from the theoretical and practical study of the atmosphere; in Avhich 
are concealed so many floating semina of disease; and whose varying 
states of heat and moisture, exert on the human constitution such 
decided effects, both for good and evil. Professor Loomis has made 
an extensive collection of meteorological instruments, of the exactest 
kind; and is most punctual, accurate and persevering in his observa- 
tions on the temperature and weight of the air, the course and 
force of the winds at the earth's surface; the direction, form and 
extent of the clouds, and quantity of rain; the state of the hygrom- 
eter, and the dew point. It is only by such observations, cotempo- 



64 



Temperature and Diseases of the Year 1842. 



raneously made in various parts of our vast platform, from the Lakes 
to the Gulf, that the laws of our climate, and its influence in modi- 
fying our diseases, can be revealed. The professor showed us a 
respectable catalogue of collaborators, residing in various parts of 
the United States, with whom he exchanges printed transcripts of 
his observations, monthly; and assured us, that he would take great 
pleasure in augmenting the number of these exchanges. We hope 
this notice may be the means of adding many to his list. D. 



TEMPERATUEE AND DISEASES OF THE YEAE 1842. 

Now that the calendar year 1842 has ended, we may affirm that 
it presented extremes between winter and summer, of much less than 
the usual extent; for while the former was one of the warmest, the 
latter was among the coldest we ever experience. This is true, Ave 
believe, of all parts of the west, from the Delta of the Mississippi, 
to the shores of Lake Superior. We may quote from Professor 
Loomis' Reports, that November and December, 1841, and January, 
February, March, and April of 1842, all had a mean heat above 
what belongs to them; while May, June, July, and August, were 
belotv their usual mean; finally, September was above it. Frost 
occurred in each summer month at Hudson, the place of his obser- 
vations, N. lat. 41° 14' 40", at an elevation of 1112 feet above the 
Ocean. Thus the climate of the west, during that year, so far as 
temperature was concerned, was much more assimilated to that of 
Europe, than Ave usually have it. Noav, the phlegmasiee of last 
Avinter, Avere as frequent and violent as usual; but from all that has 
reached us, the diseases of summer and autumn were few and mild. 
We knoAv from personal observation, that the Lake shores were 
almost as healthy as the banks of mountain rivulets, having traversed 
them extensively in July, August, and September, within latitudes 
usually infested Avith summer and autumnal fevers; and, if not "find- 
ing none," scarcely meeting with specimens enough to present their 
characteristic features. The valley of the Ohio, Avas almost as free, 
and in the South there seems to have been an equal comparative 
exemption. 

Here, then, is a cotemporaneous low temperature of summer and 
autumn, and a prevailing abatement of the epidemics of those sea- 



Pneumonia — Milk-sickness — Snake-bites. 



65 



sons? Do these agreeable phenomena stand in the relation of cause 
and effect? 

We beg our readers, every where, to favour us with their observa- 
tions on the heat, weather, and diseases of the year, to which these 
remarks relate; that we may bring them together, and see what con- 
elusion will arise (or precipitate) from the play of their affinities. 

D. 



PNEUMONIA OF THE WINTER OF 184] -'2. 

Many parts of the North, during last winter, were visited by a 
severe, in some instances malignant, pneumonia. Was it limited to 
these latitudes, or did it invade the middle and southern? If the kt- 
ter, we respectfully ask for detailed information on its symptoms, 
treatment, anatomical lesions, and sequelae, promising that the gene- 
ral results of the whole shall in due time be given to our readers. 

D. 



NORTHERN LIMITS OF MILK-SICKNESS. 

We have not been able to hear of this disease further north than 
the southern shore of Lake Erie, between Cleveland and Sandusky 
city, in N. lat. 41° 25'. On various occasions, we have expressed 
the belief, that popular opinion, both in and out of the profession, 
has greatly exaggerated the frequency and importance of this alledged 
specific disease, and our late researches have afforded us no reason 
for retracting what we have said. After spending several weeks in 
regions of country reputed to be obnoxious to the malady, we left 
them without seeing a single case, although the period of the year 
was that of its recurrence. I). 



SNAKE-BITES. 

A notice sometime since, that we were anxious to obtain infor- 
mation concerning the bites of our venomous snakes, has brought us 
several communications; some of which enclosed specimens of plants, 
said to be efficient remedies. We thank their authors, and solicit 
a continuation of their favors; but take this opportunity to say, that 
our object is rather to investigate the pathology of snake-bites, than 
6 * 



66 



Throat Disease of Public Speakers. 



the remedies on which reliance, in different parts of the country, is 
placed for their cure. In reference to the former, several curious 
questions present themselves, to which we ask attention: 

1. Are the bites of all our venomous snakes, from Michigan to 
Florida, equally pernicious? 

2. Do tliey all generate the same symptoms, differing only in 
degree? Or are there characteristic peculiarities in the diagnosis of 
each? 

3. Are any temperaments or idiosyncrasies a protection against 
the poison? What is the proportional number of deaths? 

4. Does the wound ever inflame and suppurate? 

5. Does the bitten limb swell in a few minutes, or within an hour 
or two, after the bite is inflicted? 

6. When ecchymoses appear, what is the earliest period after the 
bite, and are these spots as common in the skin generally, as they 
are on the wounded limb? 

7. From which of the mucous membranes is haemorrhage most 
frequent, and in what proportional number of cases does it occur? 
And what is the character of the blood? 

8. When death ensues, what arc the ipost-mortem appearances, 
external and internal; and in what state is the blood, &s to its colour 
and relative proximate elements? Does the body undergo decompo- 
sition earlier than usual? 

9. Is there an annually recurring irritation in the bitten part, or in 
the constitution? 

10. What domestic animals are proof against the poison? 

11. Does the "Blowing Snake" or Hissing Adder {Heterodon 
Plalirliinos of Holbrook) emit a poisonous vapour? 

12. What is the most effectual treatment, for the bites of all our 
snakes? What is the modus operandi of ammonia? Does it act as 
an antidote to the poison, or by its stimulating properties remove the 
con.stitulional irritation? 

The attention of our brethren, in regions where poisonous snakes 
abound, is respectfully invited to these inquiries. D. 



THROAT DISE.A.SE OF PUBLIC SPEAKERS. 

At the annual meeting of the Medical Convention, of Ohio, at 
Cincinnati, in the month of May last, a committee consisting of Dr. 



Throat Disease of Public Speakers. 



67 



Boerstler, of Lancaster; Dr, Sams, of Hillsborough; Dr. Fisher, of 
Waynsville; Dr. Warder, of Cincinnati; and the writer of this 
notice, Dr. Drake; was appointed to "inquire into, and report to the 
next Convention, on the causes and prevention of the chronic laryiu 
gitis of clergymen, and other public speakers." 

Communications from physicians and other gentlemen, are soli- 
cited, and may be made to either member of the committee. For 
the purpose of directing the course of inquiry, of all who may feel 
able or disposed to advance it, we present the following interrogative 
suggestions: 

1. Is not the fauces, or visible parts of the throat inflamed? And 
may not this inflammation sometimes precede that of the larynx 
which produces the flat and husky voice? 

2. Is not the inflammation of the throat, in some cases, connected 
with a dyspeptic state of the stomach? 

3. Is it not in others, associated, as a sympathetic affection, with 
chronic disease of the lungs, or of the lungs and heart? 

4. Has it increased, Avith the decline of the use of alcoholic drinks, 
more or less resorted to, in former times, to allay the irritation, and 
remove the feeling of debility in the throat, immediately after speaking? 

5. Is there any connexion of cause and effect, between the disuse 
of tobacco and the greater frequency of this malady, as suggested by 
Professor JMott? 

6. Is it more frequent where coal is the principal fuel, than where 
wood is burnt? Do clergymen and other studious persons who sit 
near stoves, keep up evaporation from noTi-metallic pans, so shallow 
as to secure a copious humidity? 

7. Are itinerant clergymen, and those who perform manual 
labor, as liable to the disease as the sedentary? 

8. Are the Episcopal clergy, who read the liturgy of that church 
with studied inflexions of voice, and generally read their sermons, 
more subject to the disease than those who read but little in public, 
and extemporise their sermons? 

9. Is the disease limited to the middle latitudes of the Union, or 
does it attack those who live on the borders of the Gulf and the 
Lakes? 

10. Is it possible to arrest the absurd application of the term bron- 
diitis, signifying an inflammation of the air tubes and cells of the 
lungs, to this affection of the organ of voice — the larynx? 



68 



Wilioughby University of Lake Erie. 



We respectfully ask. of newspaper editors, who may chance to 
meet with this article to extend its publicity. We would, also, soli- 
cit the secretaries of our different ecclesiastical conventions, confer- 
ences and assemblies, to have it read during their sessions of the 
present year, as a means of securing the attention of the class of 
men most interested in this investigation. We shall rely on our 
brethren of the medical press, to make it known to the profession 
beyond the limits of our circulation. D. 



ABOLITION OF A RULE IN MEDICAL GRADUATION.— WILLOUGHBT UNI- 
VERSITY OF LAKE ERIE. 

The readers of the "Western Journal of the Medical and Physi- 
cal Sciences," will recollect our former notices of this medical 
institution, situate in the nortii-east corner, if it can be said to have 
corners, of our great western valley. The village where it is estab- 
lished, lies eighteen miles east of Cleveland, on the bank of the 
little river Chagrin, (Chaguiu?). While in that region we spent 
an hour within the walls of tlie University edifice, and saw three of 
its professors. We are enabled to say, that it has a good germinal 
assemblage of the means of medical education, that its last class 
amounted to 57, and that its Faculty is decidedly more able, at the 
present, than any past time. But our chief object is not to make 
these facts known, seeing that most of our readers live beyond the 
region whence that school looks for pupils. 

What we aim to disseminate, is the fact, communicated to us by 
one of the Professors and also set forth in their last circular, that 
they have abolished the regulation, which allowed a four years prac- 
tice to be equal, in reference to graduation, to a course of lectures. 
We look upon this as a decided improvement in the economy of 
western schools, and hope to see it adopted by all. 

Where or when this rule was first incorporated into the code of 
regulations of our schools, we shall not stop to inquire. The first 
we ever heard of it, was in Transylvania University, on the revival 
of its' medical department in 1819. In the succeeding year it was 
adopted by the Medical College of Ohio; some years after by the 
Wilioughby school; in 1835, by the Cincinnati College; in 1837, 
by the Medical Institute of Louisville; in 1840, by the Medical 
Department of Kemper College, St. Louis; and in 1842, by the 



WiUoughby University of Lake Erie. 



69 



Medical Department of the University of St. Louis. Thus it has, 
as they successively came into existence, been made a feature of all 
the schools of the west. 

We do not question the propriety of this regulation, at tlie time, 
more than twenty years ago, when it was promulgated by the schools 
of Lexington and Cincinnati; for, as they were the first in the west, 
it embraced a great number of physicians who had, from the distance 
and difficult access of the schools of Philadelphia, New York and 
Baltimore, never attended lectures any where; and it was, perhaps, 
sound policy (we use the word in reference to the dignity of the pro- 
fession) to allow such of them, as would attend one course of lec- 
tures, the privilege of becoming candidates for graduation. But the 
rule should have been regarded as applicable only to those who 
were then in practice, and ought to have been abrogated at the end 
of the first four years; that is, as soon as all who had entered on the 
practice previous to the time of its promulgation, had had the oppor- 
tunity of availing themselves of its benefits. 

The mischiefs arising from its continuance, have, we cannot doubt, 
been very considerable. Many who would have attended one course 
of lectures, hefore engaging in practice, have been induced to post- 
pone it, till, by standing before the community as practitioners for 
four years, they could, on a single course, become candidates; and to 
shorten this probationary period, it is unquestionably true, that many 
have engaged in the practical duties of the profession, after a very 
brief period of office study, and consequently with most limited and 
superficial acquirements; which too often, have been but slightly 
extended during those years. With some honorable exceptions, 
when such "young doctors" come to our schools, they have travelled 
on the narrow and devious path, quite out of the region of rudimental 
facts and principles. Anatomy, physiolog)', chemistry and phar- 
macy, of which they know but little, are so far behind the practical 
rules and recipes of physic, surgery and obstetrics, upon which their 
minds have been directed, that they cannot be "turned back." They 
are unwilling to admit, even to themselves, that they have been going 
forth into society, as practical physicians and surgeons, ignorant of 
the elementary truths to which they find the junior students attentive; 
and, therefore, (again, with some respectable exceptions,) present 
themselves for examination, with many radical and incurable defects. 
It may be said, if they are not well prepared, let them be rejected? 



70 



Willoughby University of Lake Erie. 



But is not this a heartless remark? Is it not a serious thing, for him 
to be rejected after attending a course of lectures, who, for several 
years before he experienced that advantage, had been a practising 
physician; had acquired to some extent the confidence of his neigh- 
borhood; and might, withal, be a person of honorable dispositions? 
Is it not better, that our schools should apply a prophylactic? espe- 
cially when a dash of the faculty-pen would effectually meet the 
case? Three consequences result from the present regulation, which 
we deprecate. 1. It encourages many to engage in practice, whose 
enrolment as members of the profession, necessarily derogates from 
its scientific dignity. 2. It exposes society to all the evils which 
come from uneducated and incompetent medical guardians. 3. It 
tempts not a few to engage in the study, whose preparatory education, 
and means of future acquisition are deficient; and of course excludes 
an equal number, who might be adequately prepared. And here the 
subject expands upon us, and we shall pursue it somewhat further; 
premising that we write without consultation with our colleagues of 
the Institute, who are in no degree responsible for the opinions we 
express. 

If is a popular and amiable idea (if amiability can be predicated of 
an opinion), that medical education and graduation should be 
brought within the reach of poor young men; and so it should, if it 
can at the same time be made such as to maintain the scientific dig- 
nity of the profession, and supply the community with physicians 
and surgeons who are thoroughly acquainted with all that is necessary 
to successful practice. These latter considerations impose limits 
to facility of graduation, which cannot be passed, without trampling 
under foot the demands of the science and the safety of society. All 
regulations, then, which encourage young men, unendowed with 
academic learning and the means of prolonged and ample medical 
study, to engage in the latter, are unjustifiable. 

This mistaken beneficence to indigent young men, is a real (though 
undesigned) depredation on great interests which should never be 
overlooked. In a comparison of these, where no claims of jus- 
tice are involved, those of the majority should be respected; especi- 
ally, when by doing so the minority will not suff'er. Such Avould 
be the fact in the present matter; for it cannot be doubted, that young 
men who have neither the preparatory education, nor the means of 
adequate connexion with medical schools, would do better for them- 



Willoughby University of Lake Erie. 



71 



selves, by directing their enterprize (often of the most laudable 
kind) upon pursuits, for which they are prepared, and for -which their 
limited resources would be sufficient. It is certainly better to be a 
good merchant, mechanic, farmer or lawyer, than a bad doctor. 

The late period of the sessions of our schools, at which students 
are permitted to enter, is an evil that should be corrected. In some 
of them, the limit is the 20th of November, in others the 30th. 
In all propriety it should be the second, supposing the session to 
open the first, Monday of that month. Why should more than the 
introductory week be allowed? If the session is too long, let it be 
shortened; but no argument can be offered for not requiring students 
to be present at the opening of the regular lectures. Are not those 
of the first fortnight as important as any? We may, rather, ask 
whether the student Avho fails to hear them, Avill not be crippled in 
his intellectual movements, throughout the whole course? How can 
he get on, understandingly, without the data which are laid down in 
the seventy-two lectures delivered in that fortnight? 

But we must say a word on the early departure, not less than the 
late arrival of pupils. In every school of the United States, of 
which we know any thing touching this matter, numerous students 
go home, before the expiration of the session — unfortunately, crivii- 
nally short as it is. We have repeatedly seen young men in the 
month of February descending the Ohio river, on their return from 
the schools of the east; and not less from our venerable alma mater, 
than the younger members of the sisterhood. From every school of 
the West, they begin to depart by the end of the second week in 
February, and sometimes earlier. The rate of desertion augments 
with the time, so that by the end of the third week, the class is in a 
state of rapid decomposition, leaving for the fourth but a nucleus, 
which by the last Saturday is reduced so low, that the delivery of a 
valedictory becomes a ridiculous formality. Thus, from late matricu- 
lation and early departure, the majority of every class lose from a 
fifth to a fourth of the session. But the mischief is not confined to 
them. It extends to the more ambitious, conscientious and persever- 
ing pupils, who are disturbed and agitated by the movements of their 
friends and room-mates; so that, as every observing professor knows, 
all intense application is at an end, from the time the breaking up 
begins. We grant that the professors of a medical school cannot, 
like an academic faculty, look after and see that its pupils are punc- 



72 Corrosive Sublimate in Eryaipelas. 



tual in their attendance on the lectures; but it can be required, that 
all who intend to graduate, shall take with them at the close of the 
session, a ticket of dismission, as they receive one of admission when 
they enter. And why should not tliis be done? With a feeling bor- 
dering on sadness, Ave ask why it has not been done? Do the pro- 
fessors of our schools clierish no regard for the dignity or advance- 
ment of the noble profession confided to their guardianship? Do 
they think of nothing but the fees of tuition? Do they feel no re- 
sponsibility to society? Will they continue to measure themselves 
by themselves, and look only to the relative attainments of their 
pupils; satisfied if they graduate none who fall beneath the low stan- 
dard which harmonizes with an imperfect and superficial course of 
study? It may be said, that many young men are too poor to stay 
through the session;, to which we reply, that all such had better not 
come, but devote themselves to other pursuits. 

Let it not be said that if several of the facilities to matriculation 
and graduation in our schools, whicli now exist (but which we do 
not propose to enumerate at this time), were superseded by others, 
requiring higher preparatory attainment, longer professional study, 
and deeper scientific impregnation, there would be any deficiency of 
physicians. If it should a little diminish the aggregate number, it 
would increase the efficiency of each, and society would be better 
served, with less of that downward competition, which prevails not 
less among physicians tlian professors. The first and greatest effect 
of the new regulations would be, to invite to the study of medicine, 
those, and those only, who are well prepared by preliminary instruc- 
tion, pecuniary means, talents and ambition, to make the profound 
and varied acquisitions in science, Avhich are indispensable to the 
progressive improvement of the profession, and the safety and welfare 
of society. Many such are now excluded, because they see that 
superficial attainment, even without future study, may procure busi. 
ness; and not choosing to compete on such low ground, they turn to 
other pursuits. We might pursue this subject much further, and 
may resume it, at some convenient time. D. 



SATURATED SOLUTION OF COEEOSIVE SUBLIMATE IN ERYSIPELAS. 

By a mistake, in preparing the index to our last valume, a valua- 
ble paper on this subject by Dr. Tripler, an army surgeon, was omit- 



Tretnbles or Milk- Sickness. 



n 



ted; and therefore will not, we fear, receive the attention it merits. 
When in Detroit, the Doctor assured us of the great efficacy of this 
solution, acknowledging himself indebted for the recipe, to the very 
respectable Dr. Pitcher, formerly of the army, but now a resident 
physician in that city. A scruple of the sublimate is dissolved in an 
ounce of rain or distilled water, and lint dipped in it is laid over the 
mflamed part, being extended a short distance upon the sound. It 
gives no pain, and arrests the inflammation with great promptness. 
Doctor T. has chiefly used it in the erysipelas of the scalp and face 
of soldiers, a frequent disease in the Detroit barracks, and in no case, 
as we understood him, did the malady subsequently attack the brain. 
We would, however, refer our readers to his paper in the last num. 
ber of our last volume, to do which is the special object of this arti- 
cle. D. 



A DISCOVERY OF THE TRUE CAUSE OF THE DISEASE CALLED BY THE 
PEOPLE TREMBLES OR MILK-SICKNESS. 

This is the title of a pamphlet of forty-eight pages, from the Lou- 
isville press, laid on our table by its author, Mr. Ernst Heeringen. 
Our city is prolific in this milky literature — ourselves having led off 
in the spring of 1840; followed by Dr. Seaton, in a few months, 
with a production of nearly the same form and size; to which is now 
added a third, by Mr. Heeringen, bearing so much prima facie 
resemblance to our own, as to suggest the pleasing anticipation that 
we have founded a new school of medical literature. Our followers 
(if such they are) have, however, already got before us; as each has 
discovered the remote cause of this mysterious disorder — under which 
man turns sick and his domestic animals tremble. Unfortunately, 
however, our followers differ a little, as to the precise agent, one 
having ascertained that it is arsenic, the other malaria. So there 
they stand — "Each claiming truth and truth" — but we shall not fin. 
ish the quotation, as we wish to treat all scientific inquirers with res- 
pect. 

From the very dawn of the bright day of conjecture, which has so 
long beamed upon this subject, arsenic and malaria have been 
accused of what our rival authors have lately charged upon them; 
but although so often indicted, the profession have not yet declared 
them guilty. Should either of them be convicted, the present com- 



7 



74 



Trembles or Milk-Sickness. 



pi ainants would have no very strong claims to the merit of discovery^ 
except in the evidence by which the conviction was effected. Of 
Doctor Scaton's success, in presenting new testimony, we spoke at 
the time his pamphlet made its appearance; and are not aware, that 
he has since laid any thing conclusive before the profession. The 
style in which Dr. Seaton and his pamphlet are spoken of by Mr. 
H., shows that his "milk of human kindness" has got in it a small 
"sprinkle" of acrid poison. We extract a couple of paragraphs, as 
"a caution" to future speculatists. 

"Dr. Seaton is also wrong, when he says, that cows that are well 
salted do not go so nmch to tlie springs, and therefore receive lesa 
arsenic. Now every farrier and almost every farmer knows, that 
salt purges gently, and dissolves, and thus proves a dcductor of impu- 
rities contained in the prima via; but also they do know, that salting 
makes the animals drink more than they otherwise would have done. 
But I say, let the shoemaker stick to his last. For the correctness of 
this. 1 refer the reader to any good work on veterinary practice." 

"Arsenic is one of the most powerful mineral poisons. Who will 
be surprised, therefore, when Dr. Seaton says, dial, in giving to three 
cows sixty grains of this mineral in one day, and twenty-four grains 
at a dose, two of tliem died in forty-eight hours after receiving the 
first dose, and one of thcni was very near dead. But he has proved 
•nothing else by this experiment, except, that arsenic is apt to kill 
cows — a thing which every schoolboy knew before; inasmuch as the 
calves that were sucking the cows during the time of these experi. 
ments never felt the worse for it, and the hogs and dogs that ate the 
flesh of the dead cows were nothing the less incommoded after their 
hearty meal. I would therefore take this opportunity to say, that it 
would probably have been much better if Dr. Seaton had made the 
above experiments previously, instead of making them after having 
frightened the community by his arsenic pamphlet." 

If Dr. Seaton felt himself so much injured, by our former deco- 
rous citation of a few facts, which stood in the way of his adopted 
hypothesis, we fear he will be quite "out of patience" with Mr. 
Heeringen, to whose pamphlet we must devote the remainder of our 
article. 

Mr. H. is a German veterinary practitioner, whose style is suffi. 
ciently accurate for the object he has in view, and whose inquiries 
into the diseases of our domestic animals, give him .some fitness for 
the special investigation he has undertaken. We cannot, however, 
»ay quite so much for his logic. Having shown, as he conceives, 



Treinbles or Milk-Sickness. 



75 



that Trembles neither arise from a mineral, vegetable, nor animal 
poison, he comes boldly up to the conclusion, that it viust be pro- 
duced by malaria. The argument is, that it exists, it has a cause, 
nothing else but malaria can produce it, and, therefore, malaria does 
produce it, quod erat, &c. It was in tracing its symptomic analo- 
gies, however, that he got the first insight into its aetiology. These, as 
lie informs us, place it under the head of Anthrax fevers {febres 
ataxo adynamica) of Dietrich. As a nosological appellation he 
proposes the following as "most proper." 

"Epizootica Americana aut Fcbris ataxo acutissimus cum carac- 
tore contagloso — or in English, Trembles — which is as good a 
denomination as any that could possibly be made use of. Milk-sick- 
ness, or sick stomach, should be baptized Epidemica Americana 
Secundaria." 

For the analogies by which our author, has, to borrow his own 
language, "established on philosophical principles the diagnosis of 
Trembles," we must refer to the pamphlet itself; proceeding to state, 
what he has added to his a priori reasonings, from the a posteriori. 
This can be soon done, for avc have not been able to find a single 
fact, or one, at least, not repeatedly urged by previous advocates of 
the miasmatic hypothesis. On this point, we were unpleasantly dis- 
appointed, for as he is evidently an observing man, and has spent 
much time among the farmers, on either bank of the Ohio, we had 
hoped, that he would have contributed some new observations of a 
valuable kind. It is but just, however, that he should be allowed to 
speak for himself. 

"By analogy we have become convinced that Trembles are an 
epizootic malady; and by comparing tlicir symptoms with those of 
joint murrain, according to Dr. Dietrich's excellent work, we have 
proved that Trembles belong to the Anthrax family; we have further 
given ample proof, that Trembles are caused, neither by a vegetable 
nor a nnineral poison, but on the contrary by epizootic or miasmatic 
impurities, and tlierefore leave this portion of our task, with the assu. 
ranee that it will not be long, before all, that are interested in this 
matter, cheerfully agree, that our opinion is based upon truth and 
fact." 

This brings us to our authors means of prevention, which we are 
happy to say, even when employed but in part, have for many years, 
in all portions of the west, been found amply sufficient to prevent 



76 



Trembles or Milk- Sickness. 



the disease. As he is well acquaiated with veterinary hygieen, we 
commend to our agriculturalists all that he has said; and will vouch, 
that if they carry out his directions, their cattle will not only remain 
free from Trembles, but some other maladies, which are the offspring 
of a negligent rural economy. 

"Dr. Drake says, in vol. iv.. No. v, p. 370 of the Western Medi- 
cal Journal, that, when the cause of Trembles is discovered, the axe 
and plough will prove to be the only means by which the progress of 
the disease can be stopped. 

"This assertion is based upon experience; but we know, from the 
statement of Mr. Walker Hawes and others, that the axe alone is 
sufficient to arrest the Trembles in a short time. However, farmers 
would do well to proceed as follows: 

"First. All the trees that can be dispensed with, ought to be cut 
down and burned; so as to prevent their decaying in the place, and 
thus produce noxious malaria. 

"Second. Others that are wanted ought to be deadened. 

"Third. The buckeye, burr-oak, black-walnut, and maples ought 
to be cut down, principally, because their leaves do more damage 
than those of others. 

"Fourth. In low and marshy places, all the trees without distinc- 
tion ought to be cut down and burnt or deadened. 

"Fifth. In dry weather, fire ought to be set to the leaves and wood 
lying about in tlie forest. 

"Sixth. Dead animals ought to be buried immediately, and not 
suffered to impregnate the air with putrefaction, or to be eaten by 
hogs and dogs. 

"Seventh. Farmers ought to salt their stock every day regularly; 
for the salt cools, dissolves, and opens their bowels, and thus fre- 
quently removes the causes of some diseases. 

"Eighth. In districts where Trembles prevail, and during the 
sickly season, the milk-cow ought to be kept in a fenced lot, in 
which the timber has partly been deadened or cut down. 

"Ninth. The springs ought to be kept clean, and an outlet for the 
water ought to be made: this will prevent the water from overflow- 
ing the ground in the vicinity of the spring. 

"Tenth. Ponds must be fenced in, or the water drained off, if pos- 
sible. 

"Eleventh. Animals that are kept up where they cannot procure 
themselves water, must be watered regularly; and for this purpose a 
trough is best, set in the place where they are, and filled with good 
water. 

"Twelfth. During the hot season, animals ought to be bathed; and 
where this cannot be done, they ought, from time to time, to be 
sprinkled with fresh water. 



School for the Blind. 77 

"Thirteenth. Every animal ought, once in a month, to be purged 
•with glauber salts. 

"Fourteenth. Animals must not be suffered to go to places that 
have recently been overflowed, or where there is a good deal of stag- 
nant water. 

*' Fifteenth. When there are meal or honey dews falling, animals 
must be kept under fence. 

"Sixteenth, Animals ought not to be permitted to lie out during 
the night, but kept in stables or under fence, from sundown until 
next morning. 

"Seventeenth. It is of great advantage, if animals, in the hot sea- 
son, are kept in shady places, and not exposed to the rays of the 
sun. 

"Eighteenth. Cows ought to be bled at least once every summer." 

Our author has devoted two pages, at the close of his book, to the 
treatment of Trembles, which, he tells us, contain the results of his 
experience. They may be stated, to consist in bleeding, purging, 
towelling, and the cold effusion, for the details of which we refer to 
the pamphlet itself. 

We understand, that Mr. H. is a candidate for the premium offered 
by our Legislature, for the discovery of the remote cause of Trem- 
bles and Milk-sickness; and we sincerely hope he will continue his 
researches, until the results shall place it in his hands. D. 



SCHOOL FOE THE BLIND. 

It affords us great satisfaction to be able to announce, that the 
State, in connexion with our city, has established the school for the 
blind, of which we have already made mention more than once. It 
is now in actual operation, and cannot fail to grow, and prove a 
great blessing to a class of sufferers dear to the heart of every medi- 
cal man; because their infirmity is the offspring of diseases of the 
eye, or of our mistakes in the treatment of them. Whether from 
one cause or the other, the blind are our beneficiaries, and we should 
labor for their education and comfort. In every county of the Slate, 
there are blind children and youth of both sexes, whose parents are 
ignorant of their capabilities, under appropriate means of instruction, 
and equally unacquainted with the character of the latter, so honora- 
ble to the inventive genius and benevolence of our age. It is the 
duty, as it should be the happiness, of physicians, to seek out such 



78 



Mamrnol h Cave — Lithotoiny. 



families, and enlighten them in regard to a school, which ought to 
embrace all the uneducated blind of the State, and train them up 
to letters, music, and useful handicraft occupations. Letters request- 
ing information concerning the school, may be addressed to Mr. Bryce 
M. Patten, who will promptly and cheerfully give all the informa- 
tion required. D. 



THE MAMMOTH CAVE A WINTER RESORT FOR INVALIDS. 

We understand that our enterprising friend, Dr. Croghan, continues 
unremitting in his efforts, to make this celebrated cavern a comfortable 
winter residence, for persons affected with pulmonary disease, and 
who are unable in autumn to migrate to the distant South. We 
have been told of a medical gentleman, who spent several months 
within it, and came out greatly relieved of a pulmonary disorder — 
the particular kind was not mentioned to us. We hope that other 
physicians, who may labor under affections of the lungs, and do not 
reside at inconvenient distances, will be induced to try its effects. 
Patients not of the profession, need not hesitate to go thither, on 
account of its involving a separation from their physicians, as Dr. 
Croghan spends most of his time there, and is well qualified to give 
them advice, although not now in the practice of his profession. D. 



LITHOTOMY ON A MAN SEVENTY-EIGHT YEARS OF AGE. 

As an encouragement to the aged to submit to this operation, not 
less than an item of passing surgical news, we may mention that 
Professor Gross lately operated on a gentleman 78 years old. This 
is an uncommon age for the operation, though it has often been suc- 
cessfully performed at that time of life. The diagnosis, on sounding, 
was a small calculus, which proved to be the case; but the operator 
discovered, immediately after its extraction, that others remained, but 
were encysted. With some difficulty the cyst was broken open, 
when upwards of fifty were brought away — averaging a cherry in 
size. As usual, in such cases, they had facets, Avorn by their attrition 
against each other. This nest had evidently not been detected by 
the sound. No bad symptoms followed, and the patient is now 
restored. D. 



Progress of Temperance — Profe^ional Correspondents. 79 



PROGRESS OF TEMPERANCE. 

We hope all our readers take an interest, and "lend a hand," in 
the extirpation of alcoholic intemperance, as one of the most fruitful 
sources of the diseases they are called to encounter. Our observa- 
tions during the past summer, have convinced us, that there is a great 
and wide spread reduction in the quantity of alcohol lately consumed 
in this country. The reform, after having exerted its power in our 
garrisons to the north, has extended even among the Indians, many 
of whom liave become total abstinents. In regard to the soldiers, 
Dr. Tripler, of Detroit barracks, informed us, in the month of 
August, that, from the 1st of November, 1841, to the 29th of April, 
1842, a period of six months, through which the average number 
was two hundred and seventy-seven, there were six deaths, two from 
delirium tremens, and a third from general iatemperale habits, mak- 
ing half of the whole; but from the 1st of May, to the 18th of 
August, there had not been a death. Temperance societies are now 
established in most of our garrisons, and in nearly every village of 
the whole country. Surely a signal abatement of disease will follow 
such a reform. D. 



TO PROFESSIONAL CORRESPONDENTS. 

To prevent disappointment, we beg leave to say to such of our rea- 
ders as may have occasion to address us on professional subjects, that 
as soon as our winter labours in the Institute can be brought to a 
close, we shall descend to the Gulf of Mexico, to spend several 
months in a medical examination of the mariiime parts of Louisiana, 
Mississippi, Alabama and Florida. Should any of them, however, 
have a special reason for addressing us, the letter, if sent to Cincin- 
nati, will be forwarded in such direction as to reach us. All com- 
munications designed for the Journal, must be directed to its Editors, 
and the superscription need not include the name of either. 

Offering to our readers the compliments of the season, and iioping 
that their ledgers, on the 1st of January, may show fewer outstanding 
balances than generally disfigure and oppress a doctor's books, we 
bid them Farewell! D. 



80 



Miscellaneous Notices. 



MISCELLANEOUS NOTICES. 

Medical News and Library. — A new candidate for public patron- 
age, under this title, has just been started by Messrs. Lea & Blan- 
chard, of Philadelphia. It is to be published monthly, and in addition 
to medical news, will contain series of Lectures on the principal 
branches of medical science. These lectures will have separate 
paging and constitute "a student's library." 

Medical Examiner. — This journal has been changed from a 
weekly to a semi-monthly, and will be hereafter conducted by Dr. 
Clymer. Arrangements have been made for publishing "a regular 
series of Lectures by the prominent clinical professors in Paris." 

Wilson & Co., of New York, the publishers of what is called 
(par excellence?) "cheap literature,"have undertaken the republication 
of the London Lancet. The Lancet is edited (and Avas originally 
established) by Mr. Wakely, a member of the British House of Com- 
mons; it is of twenty or more year's standing, and is in many respects 
a valuable periodical. 

Dr. Reynell Coates, of Philadelphia, has started a literary and 
scientific journal entitled the "Literary Age." Dr. Coates is favora- 
bly known, both in and out of the profession, as a polished and facile 
writer; we heartily wish success to his new enterprise. C. 



THE 



WESTERN JOURNAL 

O F 

MEDICINE AND SURGERY. 



FEBRUARY, 1843. 



Art. 1. — An Experimental and Critical Inquiry into the 
Nature and Treatment of Wounds of the Intestines. By 
Samuel D. Gross, M. D., Professor of Surgery in the Lou- 
isville Medical Institute. 

[No. 2. — CONTISCED FROM PAGE 50.] 

Having in the preceding number of the Journal discussed 
the nature, symptoms, mode of reparation, and therapeutic 
treatment of wounds of the intestines, I shall now proceed 
to speak of the different kinds of sutures. In studying this 
branch of the subject, the reader will be struck with the 
numerous and diversified expedients that have been devised 
for the management of this class of injuries. 

1 



82 



Gross on Wounds of the Intestines. 



I. — Continued SutU7-e. 

The earliest suture employed for sewing up wounds of 
the intestines was the glover's, or, as it is generally term- 
ed by the French surgeons, the "suture du pelletier." It 
has also the name of the continued suture, and appears 
to have been extensively resorted to by the older sur- 
(reons in the management of common wounds. It was, how- 
ever, long ago rejected in the treatment of injuries of 
this kind, and was for many years entirely abandoned even 
in cases of enteroraphy of the alimentary canal. Mr. 
Samuel Cooper, in speaking of this suture, observes that it 
may, in every point of view, be now considered as totally 
disused in every case of surgery which can possibly present 
itself. "When we remember," says he, "in making this suture, 
how many stitches are unavoidable; how unevenly, and in 
what a puckered state, the suture drags the edges of the skin 
together; and what irritation it must produce; we can no 
lono-er be surprised at its now being never practised on the 
living subject. It is commonly employed for sewing up dead 
bodies; a purpose for which it is well-fitted; but for the honor 
of surgery, and the sake of mankind, it is to be hoped that it 
will never again be adopted in practice."* How far this 
sweeping denunciation is entitled to consideration, we shall 
endeavor to show in another part of this inquiry; it is suffi- 
cient, at present, to say that the glover's suture has, in my 
opinion, been unfortunately too long neglected, and that, when 
judiciously employed, it is capable of affording the most happy 
results in the treatment of intestinal wounds, no matter what 
may be their situation, direction, or extent. 

The glover's suture is usually executed with a straight, 
round needle, armed with a single waxed thread, which is 
carried from within outwards obliquely from one lip of the 



♦Dictionary of. Surgery, vol. ii, p. 831. New York, 1836. 



Gross on Wounds of the Intestines. 



83 



wound to the other, until the whole track of it is sewed up. 
The instrument should be introduced throughout at the same 
distance from the edge of the breach, and the intervals be- 
tween each two respective stitches must not be too great for 
fear of faecal effusion. The thread, moreover, must not be 
drawn too tightly, otherwise the lips of the wound will over- 
lap each other and have a puckered arrangement; an occur- 
rence which, as it is calculated to interfere with the ad- 
hesive process, should be studiously avoided. In perform- 
ing enteroraphy, the 
older surgeons were in 
the habit of leaving at 
each angle of tlie wound 
a length of thread equal 
to about five inches, 
which was brought out 
at the external open- 
ing, where it was 
secured by a strip of 
adhesive plaster, or by 
a small compress and 
bandage. In about six 
days the ligature was 
generally sufficiently 
loose to be withdrawn, 
or, if it was still pretty 
tight, the attendant cut 
it at the middle, and removed it by pulling gently at the ends. 
During this manoeuvre great care was taken to give proper 
support to the external wound. As executed at the present 
day, the extremities of the suture are fastened either by a 
knot, or by passing them under an adjoining loop, after which 
they are cut off close to the surface of the bowel, into the 
interior of which the thread employed in the operation ulti- 
mately finds its way. 

The experiments which I have performed to illustrate the 
use of the continued suture embrace the subject of transverse, 




84 



Gross on Wounds of the Intestines. 



longitudinal, and oblique wounds, and amount altogether to 
seventeen in number. I shall detail them in the order in 
which they are here enumerated, 

a. — Transverse Wounds, 

Experiment I. — ^Transverse wound of the arch of the colon two inches in ex- 
tent — continued suture — recovery. 

After considerable difficulty I succeeded in drawing out of 
the abdomen a portion of the arch of the colon, into which I 
made a transverse incision two inches in length, and sewed 
it up with the continued or glover's suture. The dog was 
large, old, and made much resistance during the operation, 
which was attended with tolerably copious hemorrhage 
from the intestinal wound. The stitches were drawn very 
tight, to insure the more accurate apposition of the divided 
parts, and considerable violence was done to the omentum 
and surrounding structures, owing to the unusual restlessness 
of the animal. Notwithstanding this, he speedily recovered 
from the shock of the operation, was in excellent spirits the 
next morning, and had altogether a most rapid convalescence. 
On the eleventh day after the experiment he escaped from 
the room in which he was confined, as well, apparently, as if 
he had not been hurt. 

Experiment II. — Transverse section of the ileum — continued suture introduced 
between the muscular and mucous coats — the animal killed on the twelfth day. 

A tarrier was submitted to the same experiment as the pre- 
ceding, with this difference, that the incision was made into 
the small bowel, and extended through the entire cylin- 
der. The needle, moreover, was carefully conveyed between the 
mucous and muscular tunics, instead of through the whole 
of them, as was the case in the former operation. The 
wound was fourteen inches from the cascum. The animal 
was permitted to live until the end of the twelfth day, wlien, 
the cure being considered sufficiently established, he was 



Gross on Wounds of the Intestines. 



85 



killed. The small bowel and omentum were extensively 
glued together by plastic lymph, in a state of organization: 
the omentum projected into the outer, and adhered to the 
surface of the inner wound: the suture still retained its hold, 
though not every where in the same degree, and the villous 
edges were united by adhesive matter. 

b. — Longitudinal Wounds. 

Experiment I. — Longitudinal wound one inch long— continued suture — the ani- 
mal killed at the end of two months and a half. 

The subject of this experiment was a large dog several 
years old; he had fasted for twenty-four hours, and was per- 
fectly well. The wound, one inch in length, was made along 
the convex surface of the ileum, a short distance from the 
caecum, and sewed up with the continued suture with such 
firmness that nothing could escape through the interstices ot 
the stitches. The day after the operation the animal was 
well, and continued so, eating and drinking with his accus- 
tomed avidity, until he was killed two months and a half 
after. The outer opening was perfectly healed with a por- 
tion of omentum in it. No adhesions existed between the 
bowels, or between these and the wall of the abdomen. At- 
tached to the outer surface of the intestinal wound was a 
process of epiploon, which thus served to mark its situation, 
which it would otherwise have been difficult to detect, so 
complete was tlie reparation. The mucous part of the breach 
was beautifully cicatrized, a slight depression being the only 
thing out of the way, and the tube retained its normal dimen- 
sions throughout. Numerous tape-worms were seen in the 
small bowel. The various tissues and organs were loaded 
with fat. 

Experiment II.— Longitudinal wound sii inches in length— continued suture— 
the animal killed on tiie twentieth day. 

The dog, as in the last experiment, was large and old. The 
1 * 



86 



Gross on Wounds of the Intestines. 



lower part of the ileum being withdrawn, I made an incision, 
six inches in length, along its convex surface, sewing up the 
whole of it with the continued suture. Considerable blood was 
lost during the operation, which was painful and protracted. 
The next day the animal was thirsty, looked stupid, and had 
occasional vomiting. Some blood, which had evidently pro- 
ceeded from his wounds, was found on the floor of the room. 
On the third day he was quite cheerful, took some meat that 
was ofliered him, and from this time on he rapidly recovered. 
He was permitted to live until the twentieth day. 

The outer wound was perfectly healed, with a small pro- 
cess of omentum intervening between its inner edges. The 
bowels were free from adhesions, except at the seat of the 
injury, where two folds were connected to each other and to 
a piece of the mesentery. On laying open the tube, a verti- 
cal fissure, three, inches long by three lines in width at the 
middle, was discovered as the remains of the original wound. 
The bottom of the chasm was formed by a process of the 
mesentery, which was firmly attached to the exterior of the 
bowel, and exhibited a smooth, transparent appearance. The 
mucous lining was puckered, or thrown into numerous hori- 
zontal rugee, like those of a ruffle, and along the edges of the 
fissure it was rounded off, elevated, and somewhat irregular. 
The caliber of the intestine was nearly a quarter of an inch 
wider than above and below the wound. All the other vis- 
cera were healthy, and the animal was in good condition. 
Every trace of suture had disappeared. 

Experiment III. — ^Wound two inches long — continued suture — the everted mu- 
cous membrane pared off— -tlie animal killed at the end of the third month. 

The dog, the subject of this experiment, had fasted for 
twenty-four hours; he was small and several years old. The 
wound, situated five feet and a half from the ileo-coecal valve, 
was two inches long, and united with the continued suture, 
the stitches being so near each other as to leave nu chance 
for the escape of any thing through their interstices. The 



Gross on Wounds of the Intestines. 



87 



everted mucous membrane was carefully pared away, and the 
■whole returned in the usual manner. The recovery was 
rapid, and three months after the operation the dog was killed. 
The suture, indeed every trace of ft, had disappeared, the 
breach being thoroughly repaired, and the continuity of the 
villous membrane re-established. A small process of the 
omentum adhered to the surface of the affected intestine, and 
another projected into the outer opening, but was in progress 
of absorption. The caliber of the tube was in no wise dimin- 
ished. No adhesions existed between the different convolu- 
tions. 

Experiment IV. — Longitudinal wound two inches in length — continued suture — 
the everted mucous membrane pared off— the animal killed at tlie end of a 
rtionth. 

The dog was small and about eighteen months old; the wound, 
situated within a short distance of the ileo-csecal valve, and 
two inches in length, was closed in the same manner as in the 
preceding experiment, and the everted mucous membrane 
pared off on a level with the serous surface. The animal had 
been fed a few hours previously, and vomited several times 
immediately after he was removed from the table. The next 
day he appeared comfortable, and quarrelled with his com- 
rades for his part of the rations. On the 21st of September, 
precisely one month after the operation, being rather lean, 
but in good health, he was killed. The omentum, as in the 
preceding case, adhered to the small bowels, and a process of 
it was prolonged into the outer wound, which was perfectly 
healed. There was no appearance of recent peritonitis; a 
part of the ligature employed in making the suture was still 
retained, but the wound was beautifully cicatrized, and the 
cure completely established. The caliber of the tube was 
natural. 



88 



Gross on Wounds of the Intestines. 



Experiment V.— Longitudinal wound two inches long — continued suture with 
the everted mucous membrane pared off— the animal killed on the twenty- 
eighth day. 

This experiment, as well as the next two, was merely a 
repetition of the preceding. The wound, situated four feet 
from the ileo-ccccal valve, was of the same length and treated 
precisely in the same manner, the everted villous membrane 
being cut off close to the peritoneal surface. The animal, 
small and rather young, was in good condition when he was 
killed on the twenty-eighth day. The post-mortem appear- 
dnces did not difler materially from those observed in the 
preceding case. The outer wound was healed with a piece 
of omentum in it, and the inner was also nearly repaired, but 
the suture was only partially detached, being retained by a 
small slip of mucous membrane. There was no adhesion 
between the folds of the intestines, or between these and the 
wall of the abdomen, nor any contraction of the caliber of the 
tube. In short, the cure was complete. 

Experiment VI. — Wound two inches long — continued suture — the everted mu- 
cous membrane pared off — the auiinal killed on the twenty-eighth day. 

The subject of this operation was a small young slut; and 
the wound, not quite two feet from the ileo-ca!cal valve, was 
treated as in the two last experiments. The next day a large 
piece of omentum, dark, bloody, and covered with dirt, was 
found protruding from the external wound; it was immedi- 
ately encircled with a ligature, and excised. The animal, 
notwithstanding this untoward circumstance, speedily conva- 
lesced, and was allowed to live until the twenty-eighth day, 
when she was killed. The internal wound was nearly healed, 
but a part of the suture still remained, a few of the stitches 
not having ulcerated away. The larger part of the thread 
was lying loose in the bowel, incrusted with solid faecal mat- 
ter. The whole would probably have been detached in a few 
days. The small bowels were slightly united to each other 



Gross on Wounds of the Intestines. 



89 



and to the omentum by plastic lymph, and the outer wound 
was thoroughly cicatrized. The animal had not lost any flesh 
from the effects of the operation. 

Experiment VII. — Wound two inches and a half long — continued suture — the 
everted mucous membrane pared off — the animal killed on the tenth day. 

The dog was large, several years old, and had fasted twenty- 
four hours. The wound, situated along the convex surface 
of the ileum, within two feet of the cascum, was two inches 
and a half long^ and closed as in the preceding experiments, 
the mucous membrane protruding through the interstices of 
the stitches being carefully pared away on a level with the 
serous surface of the bowel. About five ounces of blood 
were lost during the operation, which was somewhat pro- 
tracted, owing to the inordinate resistance of the animal. 
The bleeding had not ceased when the bowel was returned. 
No untoward circumstance occurring, and the cure being con- 
sidered established, the dog was killed on the tenth day. A 
large plug of omentum filled the external wound, the edges 
of which were already firmly united. The small bowels were 
extensively adherent to each other and to the epiploon; the 
suture retained its hold throughout the greater part of its 
extent, and a layer of lymph occupied the interval between 
the villous margins of the breach. The tube at the seat of 
the injury contained faecal matter, and presented no contrac- 
tion. The marks of acute peritonitis which generally super- 
venes upon a lesion of this kind, had entirely disappeared; or, 
rather, no more inflammation had existed than was necessary 
to effect the reparation. 

ExPERiMEKT VIII. — Wound one inch long — continued suture introduced be- 
tween the mucous and muscular tunics — the animal killed on the fifteenth day. 

Wishing to ascertain whether the edges of the wound could 
not be more perfectly approximated by carrying the needle 
between the muscular and villous tunics, or, in other words, 
through the cellulo-fibrous lamella, described in a previous pari 



90 



Gross on Wounds of the Intestines. 



of this essay, I instituted this and the following experiments. 
Drawing a loop of the ileum from the abdomen of an old 
tarrier, I made a longitudinal incision, one inch in length, 
along its convex surface, not far from the caecum, and sewed 
it up by carrying the needle, as just intimated, between the 
villous and muscular tunics. As had been anticipated, my 
expectations were not disappointed. The operation, without 
being more painful or protracted than when executed in the 
ordinary manner, had the effect of bringing the surfaces 
of the incision into the most perfect apposition. No severe 
indisposition followed, and the animal was permitted to live 
until the fifteenth day, when he was killed and his body care- 
fully inspected. On laying open the bowel, which was closely 
attached to two adjacent coils, as well as to the omentum, 
the suture was found to be only partially detached, and to be 
incrusted with small nodules of fcecal matter. The continuity 
of the villous surfaces was re-established through the medium 
of a thin, narrow band of lymph, which was removed b}'' 
maceration for two days in water. There was no abnormal 
redness either in the mucous or in the serous coat of the 
bowel, nor any contraction of its caliber. The continuity of 
the serous lips of the wound was unusually perfect. The 
outer opening was healed, a process of omentum being pro- 
longed into it. 

Experiment IX. — Wound one inch and a half long — continued suture intro- 
duced through the cellulo-fibrous lamella — the animal killed at the end of the 
thirty-fifth day. 

The subject of this experiment, a large dog, several years 
of age, had fasted for twenty-four hours. The wound, occu- 
pying the inferior extremity of the ileum, was eighteen lines 
in length, and closed precisely as in the preceding experi- 
ment. The animal vomited several times within a few min- 
utes after the operation, and appeared considerably exhausted. 
The next morning, however, he had recovered his wonted 
activity and cheerfulness, and rapidly convalescing, remained in 
good health until the thirty-fifth day, when he was killed. 



Gross on Wounds of the Intestines. 



91 



The dissection revealed the following appearences. The 
outer wound was perfectly healed, and there was no adhe- 
sion between the bowels, or between these and the omentum, 
except immediately around the seat of the injury. No trace 
of suture was discovered; the villous edges had a rough, 
granulated aspect, and were united in the greater part of 
their extent; the wound was scarcely an inch long; the mu- 
cous membrane was free from inflammation; and the canal 
was of the normal dimensions. The dog was rather lean. 
All the other abdominal viscera were sound. 

Experiment X. — Wonnd three-quarters of an inch long — continued snture 
introduced through die cellulo-fibrous lamella — the animal killed at the end of 
thirty hours. 

The animal was asmall but full grown slut. The wound, situa- 
ted in the ileum eighteen inches from the ileo-caecal valve, was 
nine lines in length, and closed in the same manner as in the last 
two experiments. The animal did not seem to mind the ope- 
ration, and was well up to the moment she was killed thirty 
hours after. The object I had in view in destroying her so 
soon, was to ascertain the progress which nature had made 
towards reparation. The outer wound, closed by a plug of 
omentum, was feebly united by adhesive matter. Three 
knuckles of the small bowel were agglutinated by plastic 
lymph, of moderate firmness, with here and there a small 
ecchymotic speck. The epiploon covered the outer surface 
of the intestinal wound, and had a red, inflamed appearance 
for some distance around it. The edges of the villous mem- 
brane were of a pale lilac color, flat, and separated only by a 
very narrow, thread-like band of adhesive matter. There 
was no contraction of the bowel at the seat of the lesion, and 
no obstruction to the passage of faecal matter. A drawing 
ol this specimen was made immediately after it was exam- 
ined. It was then immersed in dilute alcohol, which had the 
effect of depriving it in twenty-four hours of its red color, 
and of detaching the eflfused lymph. 



92 



Gross on Wounds of the Intestines. 



Experiment XI. — Wound one inch long — continued suture introduced througa 
the cellulo-fibrous lamella — tlie animal killed at the end of the fourth day. 

Anxious to investigate this point a little further, I repeated 
the last experiment upon a large dog laboring under an attack 
of mange. He had fasted for eighteen hours, and bore the 
operation without a struggle. The wound was twelve lines 
in length, and situated in the inferior extremity of the ileum, 
within eleven inches of the ca3cum. At the end of the fourth 
day, without apparently suffering from the effects of the ope- 
ration, he was killed. The edges of the outer opening were 
pretty firmly united by adhesive inflammation with an inter- 
vening process of omentum. The omentum also adhered to 
the intestinal wound, as well as for a short distance around 
it; and the injured part was firmly glued to a neighboring 
convolution. The lymph which served as the connecting 
medium was of good firmness, and exhibited all the phenom- 
ena of incipient organization. The wound itself was reduced 
to nearly one-half its original length, and the edges, of a pale 
rose color, were separated by a thin narrow band of adhesive 
matter. The villous membrane presented no unnatural red- 
ness, nor was there any inflammation of the omentum, except 
in the immediate vicinity of the injury. No obstruction 
existed to the passage of the faeces. 

Experiment XII.— Wound one inch long— continued suture carried through the 
cellulo-fibrous lamella — the animal killed at the expiration of forty-eight hours. 

The subject of this experiment was a small young slut, 
four or five months old, which had been fed only a short time 
before the operation. The incision, an inch long, was made 
in the lower part of the small bowel, and approximated by 
the continued suture. She was killed at the expiration of 
forty-eight hours, having been previously in good spirits. 
The outer wound was somewhat tumid and but feebly united, 
a plug of omentum projecting into it. This apron-like mem- 
brane had likewise contracted extensive adhesions to the 



Gross on Wounds of the Intestines. 



93 



urface of the small intestines, and exhibited all the eviden- 
ces of high inflammation. The affected cylinder was inti- 
mately connected to the adjacent knuckles by plastic lymph, 
containing a number of small bloody depots, and readily 
yielding under the pressure of the finger. On breaking up 
these adhesions the serous lips of the wound were found to 
be in close contact with each other, and to be thoroughly 
coated with the substance just mentioned. The villous edges 
were of a deep rose color, as was also the mucous surface for 
some distance above and below, and the ligature retained its 
situation throughout the whole line of suture; scarcely any 
lymph intervened between them, and they were perfectly 
smooth and regular. The bowel was not contracted or di- 
minished in size. 

c. — Oblique Wounds. 

^sPERiMEifT I.— Wound one inch long — continued suture introduced through 
all the tunica, except the serous — the animal killed at the end of the tenth day. 

A small, full-grown dog, which had previously fasted, 
formed the subject of this experiment. The wound occupied 
the convex surface of the small intestine, three feet from the 
ileo-ccEcal valve, and was closed by the continued suture, the 
needle being carried through all the tunics, excepting the 
outer. By this management the serous surfaces were brought 
into pretty close contact with each other. No untoward 
symptoms occurring, and the cure being considered establish- 
ed, the dog was killed at the end of the tenth day. The 
small bowels were extensively connected to each other, as 
well as to the omentum, and no little difficulty was experi- 
enced in finding the wound. The suture still retained its 
place, except at one extremity of the breach, where it was 
detached, and hung loose in the canal. The villous edges 
were somewhat rough and elevated, and intervening between 
them was a small, narrow band of lymph, interrupted at 
several points of its extent; the affected part of the tube was 
2 



94 Gross on Wounds of the Intestines. 



of the natural dimensions; the abdominal wound was only 
partially healed; and a process of epiploon projected into it. 

Experiment II. — Wound of the ileum three-quarters of an inch long — continued 
suture introduced through the cellulo-fibrous lamella — recovery — the dog killed 
on the twenty-second day. 

The wound in this experiment was three-quarters of an 
inch long, and closed by the continued suture introduced 
through the substance of the cellulo-fibrous lamella. Its dis- 
tance from the ileo-coecal valve was about three feet. The 
dog, which was young and of middle size, made considerable 
resistance during the operation, which had the eflect of pro- 
ducing some exhaustion, followed by vomiting immediatelv 
after he was removed from the table. The next day he was 
dull and drowsy, but from this time he gradually recovered, 
and lived until the twenty-second day, when he was killed, 
being fat and healthy. The small bowels were adherent to 
each other and to the omentum, but not in so great a degree 
as in the preceding case. A delicate process of the omentum 
was attached to the intestinal wound, the villous margins of 
which were in close contact with each other, their continuity 
being quite perfect at several points. The suture had ulcera- 
ted away, except at the upper angle of the wound, where it 
still retained a feeble hold. The bowel was of the normal 
size, and contained semi-fluid faecal matter. The abdominal 
opening had healed without the intervention of the epiploon. 

Experiment III. — Wound one inch and a half long — suture introduced between 
the nuiscular and mucous tunics — recovery — the animal killed on the seven- 
teenth day. 

A fold of the small bowel having been drawn from the abdo- 
men of a large dog, twenty hours after he had taken food, an 
incision, one inch and a half in length, was made along its 
convex surface, and the edges approximated as in the last 
experiment. The animal bore the operation without much 
resistance, and experiencing no ill-effects from it, he was 



Gross on Wounds of the Intestines. 



95 



killed on the seventeenth day. The appearance revealed on 
dissection did not vary materially from those in the preceding 
cases. The external orifice, only partially cicatrized, had a 
plug of omentum in it, and this membrane also adhered, 
though not extensively, to the convolutions of the small intes- 
tines. The wounded portion of the tube had contracted very 
firm adhesions to the mesentery, which thus served to re-es- 
tablish its continuity. The villous margins, rough and slightly 
elevated, were in intimate apposition with each other, but 
the adhesion between them was easily destroyed, except at 
one point, where the connecting medium was more dense 
and more completely organized. The breach was not more 
than thirteen lines in length, unaccompanied, however, with 
any sensible puckering of the mucous membrane, or diminu- 
tion of the caliber of the affected cylinder. The suture was 
loosened in the greater part of its extent, but only partially 
detached. 

The results of these experiments are eminently favorable 
to the use of the contined suture, as not one proved fatal, 
although the wounds in several were of extraordinary length.* 
In eight the needle was carried through the whole thickness 
of the bowel, and in five, the everted mucous membrane was 
pared off on a level with the surrounding surface; in eight, the 
suture was introduced through the fibrous lamella, or between 
the muscular and mucous coats; and in one, through all the 
layers of the tube, except the peritoneal. It is worthy of 
remark that the caliber of the tube was not sensibly dimin- 
ished by the operation in any of the experiments. 

Of these three methods, that of introducing the suture 
through the cellulo-fibrous lamella is the least objectionable, 
as it enables us to bring the serous surfaces into more accu- 
rate apposition. When the needle is conveyed through all 
the tunics, there must necessarily be some degree of pucker- 



»It is proper to state that three of the animals were killed too 
soon after the operation to render it at all certain that they would have 
recovered from the etfects of it. 



96 



Gross on Wounds of the Intestines. 



ing, whereby the mucous lining will be forced between the 
lips of the wound, if not beyond the level of the peritoneal 
membrane. By such an arrangement the adhesive process 
would be retarded, and if the stitches were to lose their hold, 
or if the bowel should not become glued to the neighboring 
parts, fsecal effusion might occur, followed by its whole train 
of evil consequences. 

In making the continued suture I would, therefore, recom- 
mend that the needle be carried through the cellulo-fibrous 
lamella, or between the muscular and mucous membranes, 
and not across all the tunics, as is generally advised by au- 
thors. The lips of the wound should be held parallel with 
each other during the operation, and the stitches, drawn with 
considerable firmness, should not be more than a line, or, at 
farthest, the eighth of an inch apart. The needle is to be 
introduced a short distance, say half a line, from the perito- 
neal edge of the opening,* and brought out at the correspond- 
ing point on the opposite side. The first stich should be one 
line from one angle of the wound, and the last about the 
same distance from the other, care being taken to secure each 
with a double knot, and to cut off the extremities of the 
suture close to the surface of the tube. The instrument 
Avhich I prefer, and which I employed in nearly all my expe- 
riments, is a long, slender sewing needle, armed with a waxed 
and strong but delicate silk thread. The operation should be 
performed as expeditiously as is consistent with safety, and 
the bowel handled in the gentlest possible manner. 

Mr. Travers, to whose name I have already so frequent- 
ly referred, and who is one of the most able and influential 
advocates of the glover's suture, performs the operation with 

* It should be recollected that in wounds of the bowels there is always 
considerable retraction of this membrane, by which the other tunics are 
exposed. Hence if the needle be introduced half a line behind the peri- 
toneal edge of the opening, as recommended in the text, it will be at 
least the eighth of an inch from the mucous margin, and this will afford 
the surgeon a sufficient amount of substance to prevent any laceration, 
or breaking away of the stitches. 



Gross on Wounds of ike Intestines. 



97 



a small round sewing needle, armed with a silk thread, 
and passed near to the lines formed at the bases of the ever- 
ted lips. The thread is carried at short and regular distances 
through the whole extent of the wound, the surgeon being 
mindful that an equal portion of the edges is included in 
each stitch. When the suture is finished, the ligature is se- 
curely fastened, and cut close to the knot. The reduction 
of the prolapsed fold, he adds, should be conducted with 
the nicest caution; and he recommends that the outer wound 
should be treated with a stitch, a plaster, or a poultice, as 
circumstances may dictate.* 

In the management of injuries of this kind, Mr. Travers 
strongly insists upon the three following points; first, the ac- 
curate closure of the intestinal wound; secondly, the careful 
reduction of the protruded part; and thirdly, the union of the 
divided integuments. The treatment of the two wounds is 
thus made perfectly distinct, the internal suture falls into the 
bowel, and the whole process is materially simplified. 

Another advocate of this suture, of no mean authority, was 
the late Baron Larrey, t whose experience was perhaps more 
extensive than that of any other surgeon that ever lived. 
His opportunities for treating wounds of the bowels in the hu- 
man subject were unusually great, and he likewise performed 
a considerable number of experiments upon the inferior ani- 
mals. After having made one or more incisions into the 
alimentary tube, in different directions, and in dogs of dif- 
ferent ages, he united their edges by means of the "suture 
du pelletier," with the precaution of making it double, using 
alternately threads of different colors. He di.'ects that the 
threads should not only be waxed, but anointed with mild 
cerate, to facilitate their introduction, and that they should 
be of sufficient length to be left hanging out of the abdon.- 
inal wound. He advises that they should not be removed 
before the seventh day, and in some cases not even before 



•Op. cit., p. 138. 

+ Surreal Essays, translated by Dr. Revere, p. 23^. 

2 * 



98 



Gross 071 Wounds of the Intestines. 



the ninth. To extract them, it is only necessary to draw 
them gently in opposite directions, which may be easily 
done, as they are of different colors. 

Sir Astley Cooper also speaks * favorable of the contin- 
ued suture; but, like Larrey, he directs the end of the thread 
to be brought out at the external orifice, which is to be 
closed with great care. He thinks that cutting off the liga- 
ture near the bowel has a tendency to add to the danger of 
the patient, especially when there is a deficiency in the 
adhesive process; an opinion for which there is no just 
ground. 

Mons. Velpeaut likewise prefers this suture, of which he 
has lately suggested the following modification: — In per- 
forming it, says he, the needle is carried obliquely down, 
wards from the upper end of the gut over the outer surface 
of the lower, from which it is returned to within a line or 
two of the starting point, passed again to the lower lip, then 
back to the first, and so on alternately until it has traversed 
the whole track of the wound. To complete the operation 
nothing more is necessary than to draw in opposite direc- 
tions the ends of the ligature, one of which will be at the 
origin, the other at termination of the suture. The object 
of this traction is to invert the edges of the wound and bring 
the serous surfaces into contact, but as this does not always 
answer, it may be proper to use a probe or catheter. The 
operation is finished by making a double knot. In morti- 
fied hernia, the ends of the thread, or even one of them, 
would be sufficient for retaining the bowel behind the ring, 
supposing it was not desirable to let it slip into the belly; 
and in this event the knot would also be unnecessary. 

-I shall conclude this subject with the following cases, 
which, so far as I know, are the only ones in which the con- 
tinued suture was employed in the human subject, or, rather, 
in which the particulars have been communicated to the pro- 



*Lecturrs, by Tyriei!, u. 4!>7. 

t Medicine Opcratoirr. T. 4, p. i;^'". 



Gross on Wounds of the Intestines. 



99 



fession. From the antiquity of the operation, however, there 
can be no doubt that it has been often resorted to by prac- 
titioners, and it is to be regretted that our information re- 
specting it is so limited. 

Case I. — Two perforations of the ileum with a knife — protrusion of the bowel 
— each opening closed with a continued suture — recovery in five weeks.* 

Antonia Josie da Costa was stabbed, on the 3d of Au- 
gust, with a knife in the right hypogastric region, about 
three fingers' breadth above the pubic bone, the wound in 
the peritoneum being about nine lines in length. Through 
this opening a portion of the ileum protruded about ten or 
twelve inches, and presented two apertures opposite each 
other large enough to admit a finger. After clearing away 
the grumous blood, Mr. Peter Travers, a surgeon of Lisbon, 
who attended the case, closed each perforation with an unin- 
terrupted suture, the ends of which were brought out at the 
external wound, which was sewed up in the usual manner. 
During the first four or five days after the accident, the man 
had severe pain in the abdomen, high fever, frequent vomit- 
ing, and hiccough. By repeated bleedings and clysters these 
symptoms gradually subsided, and towards the end of the 
fifth day he had a natural alvine evacuation. The internal 
sutures came away spontaneously on the twelfth of August, 
and on the seventh of September the patient was discharged 
in good health, the outer wound being entirely cicatrized. 

Case II. — Wound of the colon attended with the escape faces — patient eigh- 
teen years of age — continued suture — recovery. 

This case is reported by Glandorpius.f an old surgeon, but 
it is deficient in some important details, a circumstance which 
detracts considerably from its value. The patient was a young 



* The Philosophical Transactions of the Royal Society of London, 
abridged, vol. xi., p. 73. 

t Speculum Chirurg. Obs,, 34— Travers, op. cit., p. 168. 



100 



Gross on Wounds of the Intestines. 



man 18 years of age, and the wound, the size of which is 
not stated, occupied the colon, and permitted the faeces to 
escape externally. Glandorpius employed the glover's suture, 
and although the symptoms were for sometime of a very un- 
promising character, complete recovery ensued. In another 
case, in which the wound implicated the ileum, and was 
plentifully besprinkled with an astringent powder, the patient 
died of gangrene on the fourth day. 

Case III. — Two transverse wounds of tlie small bowel — continued suture — 
attachment of the mesentery to the outer opening by two ligatures — recov- 
ery in tliirty-six days.* 

An Austrian soldier, in a scuffle with one of his comrades, 
was stabbed with a knife in the right side of the abdo.- 
men, about an inch above the umbilicus. The wound was 
transverse, about three inches long, and gave vent to a very 
considerable quantity of the small intestines. The patient 
being immediately conveyed to the Hotel-Dieu at Chalons- 
sur-Marne, Mons. Charliar, the surgeon-in-chief, discovered 
that the protruded gut was divided in two places; at one, in 
about one-half of its circumference, and at the other, about 
one-fifth. Passing a loop of thread through the mesentery 
behind each injured knuckle, he sewed up the wounds with 
the continued suture, and returned the whole into the peri- 
toneal cavity. The two sutures were maintainied near the 
edges of the outer opening, by means of the threads in the 
meseritery, which were fastened by an appropriate bandage 
to the surface of the abdomen. Emollient fomentations 
were applied to the belly, and the patient was kept in the 
semi-erect posture by pillows placed behind his back. For a 
month the most rigid regimen was observed. The ligatures 
were withdrawn at the end of a few days, as soon as it was 
was found that the intestine had contracted firm adhesions to 
the inner surface of the wall of the abdomen. The outer 

* Dictionnaire des Sciences Medicales, T. 43, p. 48. 



Gross on Wounds of the Intestines. 



101 



wound cicatrized rapidly, and the patient left the hospital per- 
fectly cured on the thirty-sixth day. 

Case IV. — Large sabre wound of the ileum — extensive protrusion of the 
small bowel — escape of stercoraceous matter — patient twenty-three years of 
age — continued suture— complete recovery in less than seventy days.* 

The subject of this case was John Baptist Jolin, about 
twenty-three years of age, a fusileer in the sixteenth regiment 
of the guard. While plajdng with one of his comrades, he 
fell by accident upon the point of his sabre, which he held 
unsheathed in his hands, and which made a deep wound in 
the abdomen. He was carried to the neighboring village of 
Pucteau, where Mons. Carre sewed up his wounds. The ex- 
ternal opening, about fifteen lines in extent, occupied the 
lower part of the right side of the abdomen, and gave vent to 
a large portion of the ileum which was already tumefied. 
"I examined the protruded bowel," says Mons. Carre, "and 
found a large wound, attended with a discharge of stercora- 
ceous matter, which obliged me to make a suture at this 
point, immediately after which I returned the intestine into 
the cavity of the abdomen, dressed the parts, and sent the 
patient to the Hospital of the Guards at Paris." During the 
journey, which was tedious, he vomited copiously, and had 
one bloody stool. 

On removing the dressings, immediately after his arrival 
in Paris, a portion of the small intestine, which had become 
prolapsed during the journey, and presented a swollen appear- 



• I am indebted for this and the following case to Baron Larrey. 
The first is recorded in his Surgical Essays, edited by Doctor Re- 
vere; the other in his Memoirs of Military Surgery and Campaigns 
of the French Armies, translated by Dr. Hall of Baltimore, (vol. ii. 
p. 387.) Although it is not positively stated that the suture employed 
in these cases was the continued, yet there is strong reason to be- 
lieve that it was, both from the size of the wound, the nature of the 
operation, and the decided preference which he has expressed for 
this method in different parts of his writings. 



102 Gross on Wounds of the Intestines. 

ance, was returned into the cavity of the abdomen without 
much effort. The patient, however, was not relieved. He 
was extremely weak and anxious, and had frequent vomiting 
of bilious matter, accompanied with violent colicky pains, 
tenesmus, and small bloody stools. On visiting him in the 
morning, Baron Larrey unbound the wound of the integu- 
ments and the opening made by the sabre in the aponeurosis 
of the great oblique muscle, when he discovered that a con- 
siderable quantity of blood had been effused into the perito- 
neal cavity, and that several of the convolutions of the intes- 
tines had already become united to each other. He there- 
fore contented himself, although the symptoms of strangula- 
tion still remained, with evacuating the extravasated fluid, 
and dressing the wound with a linen rag, spread with styrax 
ointment, the whole being secured by a suitable bandage. 

For thirteen days the symptoms were of the most violent 
character, and the patient was only saved by repeated dry and 
moist cupping of the abdomen, followed by camphorated em- 
brocations and anodyne cataplasms, and finally by the appli- 
cation of blisters, with the use of enemeta and the most 
rigid abstinence. At this period a small ligature, about 
three inches and a half long, was discharged through the ex- 
ternal wound, and there was immediately a striking ameliora- 
tion of all the symptoms. The patient grew better and bet- 
ter; the wound of the abdomen soon cicatrized; and in less 
than seventy days from the accident he was completely 
cured. 

Case V. — Two sabre wounds in the colon — extensive division of the mesen- 
tery — hemorrhage into tlie peritoneal sac — continued suture with the ends 
brought out at the the abdominal opening— death on tlie seventh day from 
inflammation and gangrene of the peritoneum and intestines. 

A grenadier was wounded with a sabre in a duel, on the 
right side of the umbilical region. A considerable portion 
of the small bowel protruded across the opening, and presen- 
ted a reddish brown appearance; it was inflated, and contain- 
ed a collection of worms. The patient suffered much pain 



Gross on Wounds of the Intestines. 



103 



and distressing anxiety; the pulse was small and thready; the 
countenance ghastly; and the extremities cold. In this state 
he had been seven hours when he was brought to the hospital. 
Baron Larrey immediately dilated the abdominal opening, to 
relieve the strangulation, and to examine the other portions of 
the tube to see whether it was injured. He found the small 
curve of the colon wounded in two places, and the mesente- 
ry extensively divided by the sword. Having extracted the 
worms, which were still alive, with a pair of dressing for- 
ceps, he introduced a suture through the lips of the wounded 
intestine, and after bathing it with warm wine, reduced it, 
taking care to retain the ends of the thread on the outside. 
A considerable quantity of black clotted blood escaped at 
this stage of the operation, showing that effusion of this 
fluid had taken place in the abdomen. The lips of the ex- 
ternal wound were approximated by a compress and roller. 
The patient was conveyed to bed, and took two grains of 
opium in sweet wine, which allayed his suffering and promo- 
ted reaction. The next day the abdomen was painful and 
tender to the touch; the urine was suppressed; the skin hot, 
and the thirst urgent. The edges of the outer wound had 
separated, but presented nothing remarkable. He died on 
the seventh day from inflammation and gangrene of the peri- 
toneum and intestines. 

On dissection the portion of bowel, formerly protruded, 
was found nearly of the natural appearance. The edges of 
the inner wound were agglutinated to each other, while those 
of the mesentery lay in folds, being united by adhesive sub- 
stance, so that it was impossible for any alvine matter to es- 
cape into the peritoneal sac. The pelvis and interstices of 
the viscera were occupied by black and decomposed blood. 
Extensive adhesion existed among the different organs; the 
lower part of the ileum was sphacelated at several points; 
and the superior mesenteric artery was divided near its origin. 
But for the latter injury, it is nighly probable, as has been 
remarked by Baron Larrey, that the man might have 
survived the wounds in the intestines, and finally recovered. 



104 



Gross on Wounds of the Intestines. 



II. — Interrupted Suture. 

It is not easy to determine, at this remote period, when, or 
by whom, the interrupted suture was first introduced to the 
notice of the surgeon. There can be no doubt, however, that 
it has been in use almost from time immemorial. The man- 
ner of performing it is too well known to require any men- 
tion in this place. The following experiments and observa- 
tions will sufficiently illustrate the value of this suture in the 
treatment of wounds of the intestines. The former are 
arranged, in reference to their direction, into three classes, 
namely, into transverse, longitudinal, and oblique. 

a. — Transvei'se Wounds. 

Experiment I. — Complete section of the small bowel — four interrupted sutures 
— the ends of the threads cut off at the knots — death from peritoneal inflam- 
mation in forty-five hours. 

Having opened the abdomen of a large dog after he had 
fasted for twenty-four hours, I drew out a fold of the small 
bowel by means of a blunt-hook, and divided it as far as the 
mesentery. The edges of the wound were then brought 
together by four interrupted sutures, placed equidistant from 
each other, and the ends cut off close to the serous surface. 
The whole being returned into its natural situation, the outer 
opening was united by two stitches, and the animal allowed 
water but no food. The operation was performed at eleven 
o'clock in the morning. In the afternoon the dog was sick 
at the stomach, threw up water several times, and lay quietly 
on his side. His thirst was not urgent, nor did he seem to 
suffer much pain. The next day he was dull and heavy, with 
occasional vomiting; his breathing became short and laborious, 
and he died in a state of coma forty-five hours after the ex- 
periment. 

The following appearances were observed on dissection. 



Gross on Wounds of the Intestines. 



105 



A process of omentum, very red and slightly adherent to the 
surrounding parts, projected into the outer opening, the edges 
of which were united by lymph. The peritoneal sac con- 
tained a pint of sanguinous fluid, and was universally in- 
flamed. Three knuckles of the small bowel adhered to each 
other, and the wound was every where covered with plastic 
lymph, except at one point, three lines long, where the clos- 
ure was imperfect, and where there had evidently been an 
escape of alvine fluid. The mucous membrane at the wound 
was slightly everted and rounded off, and exhibited all the 
evidences of high inflammation. The bowel above the seat 
of the injury was obstructed with fsecal matter, of a solid 
nature, produced apparently by a palsied state of the muscu- 
lar fibres, and not by any contraction of the canal. 

Experiment II. — Section of the entire cylinder of tiie bowel — seven interrupted 
sutures— recovery— the animal killed on the seventeenth day. 

A small slut was submitted, Semptember 4th, to the same 
experiment as the preceding, with this difference, that the 
wound was closed with seven interrupted sutures instead of 
four, about two lines from each other. She bore the opera- 
tion well, and lived without any untoward symptoms until 
the seventeenth day, when she was killed. The external 
wound was beautifully healed, and a considerable quantity of 
adeps was found beneath the skin of the abdomen. There was 
no adhesion of the bowel or omentum to the parietal portion 
of the peritoneum, and the internal wound, situated within a 
few inches of the ileo-coccal valve, was in great measure 
healed; three of the sutures, however, still retained their 
hold. No evidence of inflammation was discoverable at the 
seat of the injury, and the tube had undergone no con- 
traction. 

3 



106 Gross on Wounds of the Intestines. 



ExPERii»iENT III. — Transverse wound embracing three-fifths of the cylinder of the 
small bowel — three interrupted sutures — the ends of the ligature cut ofi" near 
tlie knots — recovery — the animal killed near the end of tlie third month. 

May 33, I divided the small intestine eighteen inches 
from the ileo-coecal valve three-fifths across, making a wound 
about fourteen lines in extent, the edges of which were 
brought together by three interrupted sutures, at equal inter- 
vals from each other, and the ends cut off as in the preceding 
experiment. The animal, which was healthy and of mode- 
rate size, had been fasting for twenty-four hours. No blood 
was lost during the operation, from the effects of which he 
speedily recovered. On the i6th of August, being in good 
condition, he was killed, and the body carefully inspected. 
The outer wound was perfectly cicatrized, as was also that 
in the bowel. The la Iter, however, was somewhat rough on 
its external surface, from the attacl)ment of a small narrow 
process of the epiploon, which was partially ulcerated, and 
would doubtless in a few days more have lost its entire con- 
nexion. Internally the reparation was beautifully perfect. 
No adhesion existed between the bowel and the wall of the 
abdomen, or between any of the intestinal convolutions. 

Experiment IV. — Transverse wound occupying four-fifths of the circumference 
of tlie tube — four interrupted sutures — the dog killed on the ninth day. 

In this experiment, which was performed on a middle-sized 
dog after he had fasted for eighteen hours, the small bowel 
was cut four-fifths across, three feet and a half from the 
ilto-cojcal valve, and the wound united by four interrupt- 
ed sutures, equidistant from each other. One end of each 
ligature was brought out at the external opening, and the 
other cut off close to the knot. The animal rapidly recov- 
ered from the shock of the operation, and lived until the 
ninth day, when he was killed. The protruding ligatures 
were detached, and the edges of the external opening firmly 
united, with a small process of omentum intervening between 



Gross on Wounds of the Intestines. 



107 



them. The internal wound was partially cicatrized, and 
exhibited well marked traces of the situation of the sutures. 
The parts immediately around were rough and knobby, from 
the presence of lymph and adherent omentum; but there was 
no abnormal vascularity or evidence whatever of inflamma- 
tory action. The bowel contained fsecal matter, and was as 
large as natural. The animal had not lost any flesh. 

Experiment V. — Transverse section embracing five-sixths of the intestinal cy- 
linder — four interrupted sutures with both ends cut off — the animal killed in 
three weeks. 

The subject of this experiment was a small pup not more 
than five or six months old. The small bowel was cut five- 
sixth across, and the everted mucous membrane pared away 
on a level with the peritoneum. I then passed the needle 
through all the coats of the intestine, hoping thereby to 
approximate more completely the serous surfaces. In this, 
however, I found myself mistaken; for no sooner did the in- 
strument enter the muscular lamella than violent contractions 
ensued, producing fully as much eversion as before. Four 
interrupted sutures, with the ends cut off close to the perito- 
neal surface, were employed, and the whole returned within 
the abdomen. The dog became sick a short time after the 
operation, and had repeated vomiting; but he gradually recov- 
ered, and escaped, at the expiration of the third week, in 
good health. 

Experiment VI. — Semi-division of the bowel — two interrupted sutures with 
one end protruding — the animal lulled on the thirty-sixth day. 

On the 10th of August, I opened the abdomen of a tar- 
rier slut, and cut the small bowel half across, three feet 
from the ileo-ccecal valve, sewing up the wound, which 
was about three-quarters of an inch in length, with two 
interrupted sutures, one end of which was left hanging out 
at the external opening. The animal experienced appar- 
ently very little inconvenience from the operation, and 



108 



Gross on Wounds of the Intestines. 



was killed in good health on the 16th of September, or the 
thirty-sixth day after. The external wound had healed 
without the intervention of the omentum, which, however, 
adhered to several intestinal folds. The internal wound was 
beautifully cicatrized; all trace of suture had disappeared, and 
there was no mark whatever of recent inflammation, either 
in the serous or mucous tissues. The tube was of the nor- 
mal size. 

b. — Longitudinal Wounds. 

ExPERiMKXT I. — Longitudinal wound two inches long — four interrupted sutures 
— the ends of the ligatures cut off near the peritoneal surface — the animal lulled 
after the third month. 

An incision, two inches in length, being made along 
the convex surface of the ileum, a little more than a foot from 
the ileo-ccEcal valve, I approximated the edges with four in- 
terrupted sutures, equidistant from each other, and cut off 
the ends close to the peritoneal surface. The dog, which 
was large and old, lost a good deal of blood during the ope- 
ration, and the wound was still bleeding, though not freely, 
when I returned the bowel into the abdomen. He rapidly 
recovered from the effects of the injury, and continued in 
excellent health until he was killed on the 22d of September, 
upwards of three months after the experiment. The epiploon 
adhered to the surface of the bowel, and a small process pro- 
jected, into the outer wound. The interval wound was per- 
fectly cicatrized, so much so, that some difficulty was experi- 
enced in determining its situation: two coils of the intestine 
were united together at the seat of the injury. The dog was 
fat, and all the viscera were free from disease. 

ExpEniMENT II.— Longitudinal wound one inch long— four interrupted sutures — 
the ends of the ligatures brouglit out at the abdominal opening — the animal 
killed on the twelflli day. 

A large healthy dog, having fasted for twenty-four hours, 
was subjected to the same experiment as the preceding, with 



Gross on Wounds of the Intestines. 



109 



this diflerence, that the wound was only one inch long, and 
that the ends of the ligatures were brought out at the exter- 
nal opening. Nothing unusal occurred after the operation, 
which he bore with comparatively little resistance. On the 
twelfth day, being considered out of danger, he was killed. 
The abdominal wound was cicatrized throughout its entire 
extent with the intervention of a plug of omentum, a small 
mass of which also adhered to the injured bowel. The 
latter was slightly agglutinated to several of the neighboring 
coils, and on laying it open the villous portion of the breach 
was found to be well repaired, the edges being rounded off, 
and connected by plastic lymph. The tube at the seat of the 
lesion contained alvine matter, and was of the natural diame- 
ter. No inflammation was observable either in the serous or 
mucous coat. It should have been stated that all the ligatures 
were detached on the sixth day. 

Experiment III. — Longitudinal wound one inch in length — four interrupted su- 
tures — the ends of the ligatures cut off close to the knots — the animal killed on 
the twenty-second day. 

This experiment was merely a repetition of the last. In- 
stead, however, of bringing the ends of the ligatures out at 
the abdominal wound, they were cut off close to the perito- 
neal surface. The dog was small but full-grown, and had fasted 
for twenty-four hours. He bore the operation remarkably 
well, appeared very sprightly soon after it was over, and 
drank a considerable quantity of water. No untoward symp- 
tom arose, and he continued perfectly well until the twenty- 
second day, when he was killed. The appearances on dissec- 
tion were found to be essentially the same as in the cases 
already mentioned. A piece of omentum was attached to 
the entire surface of the intestinal wound, the reparation of 
which was unusually perfect. All trace of suture had disap- 
peared, and the continuity of the villous surface was, in a 
great degree, re-established. There was some adhesion be- 
tween the neighboring folds of the small bowel, and a process 
3 * 



110 



Gross on Wounds of the Intestines. 



of the epiploon was prolonged, as usual, into the abdominal 
wound. 

Experiment IV. — Longitudinal wound five-eighths of an inch long — two suture? 
with the ends brought out at tlie external wound — recovery. 

The subject of this experiment was a small dog four or 
five years old. The wound, five-eighths of an inch in length, 
was made, as usual, along the convex surface of the bowel, 
and closed with two interrupted sutures. The ends of the 
ligature were twisted together, and left hanging out at the 
external opening. The animal bore the operation well, and 
was apparently in perfect health a few hours before his escape, 
which happened at the end of the ninth day. 

Experiment V. — Longitudinal wound half an inch long — one suture with the 
ends cut off at the knot — the aniiUcJ killed at the expiration of the seventh day. 

From the abdomen of a large slut I drew a fold of the ileum 
within fifteen inches of the ileo-ccEcal valve, and making a 
longitudinal incision along its convex surface, six lines in 
length, I closed it with a single suture, the ends of which 
were cut off" at the knot. No untoward symptom arising, 
and being considered past all danger from the operation, she 
was killed at the expiration of the seventh day. The outer 
opening was pretty well healed, with a portion of epiploon 
adhering around its inner margins, as well as to the surface 
of the intestinal wound, and to several neighboring knuckles. 
The suture had disappeared, reparation was going on beauti- 
fully between the villous edges, and the bowel, containing faj- 
cal matter, had experienced no change in its caliber. The 
quantity of lymph poured out by the peritoneal surface was 
very small, as was proved by the trifling nature of the adhe- 
sions. The dog was fat, and had lost no flesh from the ope- 
ration. 



Gross on Wounds of the Intestines. 



Ill 



Experiment VI. — Longitudinal wound half an inch in length — one suture with 
the ends cut off close to the knot — death on the eleventh day from causes 
apparently unconnected with the operation. 

This experiment was merely a repetition of the last. Al- 
though only one suture was employed, it seemed to have the 
effect of closing the opening completely. The dog, which 
was very small and not more than three or four months old, 
bore the operation exceedingly well, and had no untoward 
symptoms prior to his escape, which took place three days 
thereafter. He remained at large until the eleventh day, 
when he was met in the immediate vicinity of the dog-house 
in a paroxysm of convulsions, in which he was knocked on 
the head and killed. On dissection I noticed the following 
appearances. The outer opening was perfectly healed, except 
at one or two points, with a small slip of omentum pro- 
longed into it. No peritoneal inflammation was observable 
any where; the bowels did not adhere to each other or to the 
abdominal walls; the ligature was detached; and the continuity' 
of the aflected portion of the tube was re-established by a 
process of the epiploon, which was firmly attached around 
the wound for some distance. The edges of the latter were 
one-third of an inch apart at the centre; the mucous mem- 
brane was not at all red or inflamed; and the small intestine 
was empty and blanched. What caused his convulsions I 
could not determine. 

c. — Oblique Wounds. 

Only two experiments were performed with a view of illus- 
trating the treatment of oblique wounds by the interrupted 
suture, and of these the following synopsis must sufl^ce. 

Experiment I. — Wound six Unes long — tvvo intern»pted sutures through tlie 
cellulp-fibrous lamella — the animal killed at the end of the third week. 

The dog, old and of large size, had fasted for nearly twenty- 
four hours. The wound was made along the convex surface 



112 



Gross on Wounds of the Intestines. 



of the small bowel, opposite the attachment of the mesentery, 
and about twenty inches from the ileo-coecal valve: it was six 
lines in length, and closed with two interrupted sutures carried 
through the cellulo-fibrous lamella. The ends were cut off 
near the peritoneal surface. Nothing worthy of notice occur- 
red after the operation, and the dog, being in good health, was 
killed at the expiration of three weeks. On opening him I 
found that both sutures had disappeared, leaving merely a 
slight circular depression which served to indicate their for- 
mer situation. The mucous portion of the wound presented 
a linear or fissured aspect, and might be said to be in great 
measure cicatrized. The serous surface had contracted firm 
adhesions to the mesentery, and the tube retained its normal 
dimensions. The omentum adhered slightly to the small in- 
testines, and a process of it was prolonged into the outer 
wound, which was completely consoHdated. 

EspERiJiENT II. — Wound one inch and a half in lengtli — five intemipted sutures 
— the ends of the ligatures cut off close to the knots — the aninial killed upwards 
of a month after the experiment. 

The animal was small, but full-grown, and the wound, 
eighteen lines in length, was united by five interrupted su- 
tures, equidistant from each other. The ends were cut off 
close to the knots. The wound, as in the foregoing experi- 
ment, occupied the inferior extremity of the ileum. The dog 
soon recovered from the shock of the operation, and was kil- 
led oiie month and three days after. The sutures had all dis- 
appeared, and the wound was neatly cicatrized throughout, 
excepting at two or three small points, where the edges were 
somewhat elevated and puckered. It had diminislied nearly 
six lines in length. The tube was slightly contracted at the 
seat of the injury, but not sufficiently to interfere with the 
transmission of the alvine matter. Externally the bowel 
adhered firmly to two adjacent convolutions, together with a 
fold of the epiploon. The abdominal wound was entirely 
healed. 

Of the foregoing experiments, two were fatal, death being 



Gross on Wounds of the Intestines. 



113 



produced in one by peritoneal inflammation, in the other 
without any obvious cause. The suture was carried through 
all the tunics in thirteeen, and in one through the cellulo- 
fibrous lamella. In ten, both ends of the threads were cut 
off close to the peritoneal surface; in two, they were brought 
out at the external opening; and in the remainder, one ex- 
tremity was cut off, and the other secured to the surface of 
the abdomen. 

The most important circumstances to be observed in making 
this suture in wounds of the bowels are, to carry the needle 
through the cellulo-fibrous lamella, and to place the stitches 
sufficiently near each other to prevent the escape of faecal 
and other matters. It will be perceived that in some of the 
above experiments the interval between the stitches was as 
much as four or five lines, and yet no effusion occurred. Such 
a practice, however well it may answer in the inferior ani- 
mals, is certainly inapplicable to the human subject, whose 
safety should never be jeoparded by inattention to the dictates 
of sound experience. 

It will be seen that in these experiments, as in those 
with the continued suture, the caliber of the intestinal tube 
was not seriously diminished in a single instance. Indeed, in 
nearly all the cases in which the parts were examined, it was 
quite as large at the seat of the injury as in the natural state* 

I subjoin the following cases in which the interrupted su- 
ture was employed in the human subject. Taken in connex- 
ion with the experiments just detailed, they exhibit an array 
of success highly favorable to this method of treatment. 

Case I. — Extensive wonnd of the abdomen, with complete division of the ileum, 
and penetration of the thoracic cavity — four interrupted sutures — recovery in 
a month.* 

Henry Cooper, seven years of age, had his belly ripped 
open by a boar on the 23d of August, 1815, soon after eat- 
ing a small piece of bread and bacon with two apricots. 



• Edinburgh Medical and Surgical Journal, vol. xii, p. 27. 



114 



Gross on Wounds of the Intestines. 



Nearly the whole of the abdominal viscera, the stomach, a 
large portion of the intestinal canal, the mesentery, and 
omentum were protruded through an immense wound on the 
left side of the median line. The ileum was completely sev- 
ered, the omentum was lacerated through its entire extent, 
and a rent an inch long existed in the mesentery. On the 
left side of the chest was a lacerated wound five inches long, 
communicating with the cavity of the chest, and complicated 
with fracture of the fifth and sixth ribs. The wound in the 
wall of the abdomen commenced about an inch below the 
antero-superior spinous process of the iliac bone, from which it 
reached, in an oblique direction, to the right side of the ensi- 
form cartilage of the sternum. Mr. Gallon, surgeon at Col- 
lingham, brought the edges of the intestinal wound together 
by four interrupted sutures, made with a small curved needle 
and a double silk thread. A firm hold was taken by carry- 
ing the instrument through all the tunics of the gut, and each 
ligature was cut off close to its knot. The omentum was 
returned without any other attempt to approximate its divided 
edges than laying them together. The wound of the abdo- 
men was secured by sutures and adhesive straps, supported by 
a broad bandage. 

For the first forty-eight hours after the occurrence of the 
accident there was great restlessness, high fever, tender- 
ness and tumefaction of the abdomen, and irritability of the sto- 
mach. On the twenty-fifth the boy vomited up some undigested 
ham, two apricot-stones, and several lumbricoid worms, with 
great mitigation of his symptoms. The following day he had 
a copious liquid evacuation from his bowels, from the adminis- 
tration of a dose of castor-oil, aided by an enema of sulphate 
of magnesia. The external sutures came away on the twenty- 
ninth and thirtieth of August, and in a month the wounds 
were perfectly cicatrized. The little patient was of course 
much emaciated, and the wall of the abdomen, at the original 
seat of the injury, was so thin as to allow the peristaltic action 
of the intestine to be plainly seen through it. 



Gross 071 Wounds of the Intestines.. 



115 



Case IL — Four wounds of the small bowel with injury of the omentum — 
treatment by the interrupted and continued suture — recovery in a fort- 
night.* 

An athletic young man, twenty years of age, in carelessly 
handling a scythe, on the 26th of August, 1836, with the 
point turned towards the body, accidently pierced his belly 
a little above the left of the umbilicus, inflicting a longitudi- 
nal wound five inches in length externally, but not quite so 
extensive within. The omentum was perforated and the je- 
junum opened in four places. One of the wounds in the 
latter reached nearly entirely across the gut, the second rath- 
er more than one-half, the direction of both being transverse: 
of the other two, one was a mere puncture, yet sufficient to 
allow the escape of fcecal matter, while the other, which 
was a longitudinal slit, was two inches in length. A large 
mass of the small intestines, a portion of the colon, and the 
omentum protruded through the outer wound, and were found, 
nearly four hours after the accident, covered with dried blood 
and farces, the latter of which had issued in considerable 
quantities. The patient was in great suffering, his symptoms 
resembling those of strangulation of the bowels, which, in- 
deed, was the case. After thoroughly cleansing the protru- 
ded viscera with tepid milk and water. Dr. Aquila Toland, of 
Madison county, Ohio, who attended the patient, brought the 
lips of three of the wounds together by the interrupted suture, 
made with broad linen threads. The large transverse cut 
was treated with the glover's suture, that is to say, the two 
small needles which he used for that purpose were passed 
alternately from one side to the other between the mucous 
and muscular tunics, the former being pushed back and ex- 
cluded from the ligature. The parts were then returned into 
the abdomen, having previously somewhat enlarged the outer 



' Western Journal of the Medical and Physical Sciences, vol. 10, 
p. 481. 



116 



Gross on Wounds of the Intestines. 



wound, the edges of which were next brought into apposition 
and retained by the quilled suture. Two days after the ope- 
ration a small process of omentum was discovered in the 
lower angle of the external opening, upon pushing back 
which, a copious discharge of bloody pus occurred, followed 
by great relief of the hypogastric distention. On the thirty- 
first of August the patient had, for the first time since the ac- 
cident, a free evacuation from the bowels; on the fourth of 
September, all unfavorable symptoms had disappeared; and 
in a fortnight the outer wound was nearly cicatrized. 

Case III. — Perforation of the small bowel by the horn of an ox — interrupted 
suture — dilatation of the abdominal wound — complete recovery.* 

William Kemble, twenty-one years of age, of spare habits, 
a butcher by occupation, was gored in attempting to slaugh- 
ter an ox, December 11th, 1832, the horn penetrating the 
abdomen just above Poupart's ligament. Through this open- 
ing about six inches of small intestine protruded, which 
was at the same time strangulated. On examining the gut 
it was found to have been completely perforated by the ani- 
mal's horn, which had entered it on one side and come out 
at the other, producing consequently two apertures, capable 
each of admitting a finger. No faeces had escaped, nor had 
there apparently been much hemorrhage. Mr. J. D. Davids, 
a surgeon of Cowes, being called to the case, immediately 
brought the lips of the larger wound together with two su- 
tures, and those of the smaller with one, the ends of the 
ligatures being cut off close to the knots. He then attempt- 
ed to return the bowel, but found this impracticable without 
dilating the external wound, which was accordingly done 
with a probe-pointed bistoury. The outer opening was closed 
with sutures, supported by straps of adhesive plaster. For 
the first few days there was considerable restlessness, with 
vomiting and tenderness of the abdomen. On the fifteenth 



*Medico-Chir. Review, vol. xx, p. 182. 



Gross on Wounds of the Intestines. 



117 



some oil was given by the mouth, which acted very well on 
die bowels, and from this period he went on progressively 
improving. One of the sutures only made its way out 
through the wall of the abdomen, the two others fell into the 
intestinal canal, and were passed with the fajces. Complete 
recovery ensued. 

Case IV. — Oblique wound of the small intestine, tliree-fourths of an iucli 
long — four internipted sutures with the ends cut off close to the peritoneal 
surface — recovery in five weelvs.* 

M. Sullivan, aged twenty-six years, a native of Ireland, 
was admitted into the New- York Hospital, under the care of 
Dr. Buck, on the 17th of August, 1840, with a stab in the 
abdomen, received an hour before in a quarrel. The exter- 
nal wound, which was situated on the left of the median 
line, midway between the pubes and umbilicus, was an inch 
long, and gave vent to several knuckles of small intestine, 
in one of which was an oblique cut tliree-fourths of an inch 
in extent. The protruded parts were of the natural warmth 
and of a deep red color; the patient was faint and restless; 
he had frequent vomiting, with insatiable thirst; and the 
pulse was weak and small. Four sutures of fine silk thread 
were introduced into the inner wound; they included all the 
tunics of the bowel, and the ends were cut off close to the 
knots. Reduction was then attempted, but did not succeed 
until the outer cut was dilated to the extent of half an inch 
at its upper edge. The outer wound was then united 
with two sutures and adhesive strips, the whole being sup- 
ported by a broad bandage. During the first day ten 
ounces of blood were taken from the arm, and four dozens of 
leeches applied to the abdomen. On the 18th the patient 
was comfortable; there was pain, however, on pressure at the 
seat of injury; and towards evening, the pulse having increas- 
ed in force and tension, the venesection was repeated to 



* New-York Journal of Medicine and Surgery, No. 8, April, 1841. 
4 



118 Gross 071 Wounds of the Intestines. 

twenty ounces. On the 19th he made several fruitless at- 
tempts at stool, and the belly became tympanitic and some- 
what swollen; for these symptoms a large blister was ap- 
plied, and an emollient enema administered. On the 23d 
of August he was leeched on the right iliac region, and from 
this period his convalescence was completely established; 
the bowels moving spontaneously or by the aid of injections, 
and the tenderness disappearing from the abdomen. The ex- 
ternal wound healed kindly, partly by the first intention; and 
in about five weeks he began to sit up. His recovery, how- 
ever, was retarded by an attack of inflammation of the chest, 
and effusion into the cavity of the peritoneum. These grad- 
ually yielded to appropriate treatment, and he left the hospi- 
tal on the 28th of October. 

Case V. — Two incised wounds of the small intestines, each more than half 
an inch long — interrujited suture — recovery in a fortnight.* 

Ezekiel, an athletic negro, aged thirty years, in a night 
broil, was wounded in the arm and abdomen with a knife, 
the latter injury involving one of the small bowels, which 
was cut in two places to the extent of more than half an 
inch. Several branches of the mesenteric artery were divi- 
ded ■ and bled freely. The bowel protruded through the 
wound. Having washed off the coagulated blood, the divi- 
ded vessels were included in fine silk ligatures; "after 
which," says Dr. Yandell, "the openings in the gut were 
each closed with the same species of thread, but whether 
more than one stitch was used, I am not able, at this dis- 
tance of time, to say." In two weeks the man had so far 
recovered that it was no longer necessary to visit him. 



* I am indebted for the above case to my friend anri colleague. 
Professor Yandell. As it occurred more than ten years ago, and no 
notes were taken of it at the time, it is not so circumstantially re- 
pbrted as could be desired. 



Gross on Wounds of the Intestines. 119 

The following cases, although they had an unfavorable ter- 
mination, throw additional light upon this important subject. 
They occurred in the practice of Sir Astley Cooper, and are 
recorded in his great work on the Anatomy and Surgical 
Treatment of Abdominal Hernia, edited by C. Ashton Key, 
Esq. 

Case I.— Strangulated crural hernia in a woman fifty years of age — mortifica- 
tion of the ileum, and excision of the affected part — three interrupted su- 
tures with the ends protruding through the outer orifice — artificial anus — death 
on the fifth day after the operation. 

A woman, fifty years of age, had been laboring under 
strangulated crural hernia from the first until the eighth of 
November, when Sir Astley Cooper was requested to visit 
her for the purpose of performing an operation for her relief. 
Her features at this time were anxious and collapsed; the 
pulse was one hundred and thirty a minute; there was 
great thirst; the abdomen was distended and tender on pres- 
sure; the bowels had been obstinately constipated for more 
than a week; there was frequent vomiting of a yellowish fluid, 
of faeculent odor; and the tumor was red, hard, and ex- 
quisitely painful to the touch. Having laid open the hernial 
sac, a quantity of liquid faeces immediately escaped from it, 
which was found to have proceeded from a large circular open- 
ing of the ileum, with dark, thickened, and everted edges. 
After the stricture was fully divided, he cut away the morti- 
fied piece of bowel, which was about two inches and a half 
long, and joined the two fresh ends by three sutures, leav- 
ing a small aperture for the evacuation of faeces, and con- 
fining the ligature which passed through the back part of the 
tube next the mesentery to the mouth of the hernial sac. 
The external wound was closed in the usual manner, except 
at one point for the passage of alvine matter. She died on 
the morning of the 12th of November, every thing that she 
swallowed having in the mean time been speedily discharged 
at the groin. The integuments over the artificial anus were 
of a livid color, but not mortified, and she had no passage 



120 



Gross on Wounds of the Intestines, 



since the attack. On dissection the protruded part of the 
tube was found to be firmly glued to the inner side of the 
sac, and the small bowel above this point highly inflamed 
throughout. The stomach was pale and contracted; the large 
intestine was free from disease; and there was no effusion of 
fluid into the peritoneal cavity, nor any adhesion of the ab- 
dominal viscera. 

Case II. — Strangulated crural heniia — patient sixty-eight years old — mortifica- 
tion of the bowel — excision of the aifected part — three interrupted sutures 
with the ends protruding through the outer orifice — artificial anus — death in 
ten weeks. 

This case was likewise one of crural hernia; the patient 
was a female, sixty-eight years of age, and the strangulatiof 
had existed for five days. When Sir Astley Cooper saw her, 
on the 31st of July, she had repeatedly vomited, and there 
was slight hiccough, with a small and frequent pulse. The 
tumor was much inflamed, and pitted under pressure. After 
exposing the bowel, he discovered that it was mortified to the 
extent of about three-quarters of an inch, and that there were 
two holes in it, one of which was large enough to admit the 
blunt eni. of a probe. Both apertures were of a circular 
form, and readily permitted the escape of fscal matter when 
pressure was applied to the adjoining portions of the tube. 
With a pair of scissors he cut away the sphacelated piece, 
and then united the parts by three sutures. The divided 
edges bled freely, but the hemorrhage was checked when the 
ligatures were drawn together. The intestine was then push- 
ed as near as possible to the mouth of the hernial sac, and 
the threads left hanging from the wound. The protruded 
omentum was cut off, and the external opening every where 
closed, except at the centre, to allow of the escape of fa?cal 
matter, should it be disposed so to do. 

On the second day after the operation a large quantity of 
liquid fasces passed from the wound, and in a short time 
afterwards the artificial anus appeared to be fully established 
the opening into the bowel being large enough to admit the 



Gross on Wounds of the Intestines. 



121 



finger. From this time until the twenty-third of September 
the case presented nothing of any particular interest. At 
this period the wound was very much contracted, the hole in 
the bowel was greatly reduced in size, and all discharge of 
fasces had ceased, owing, as was supposed, to her having 
eatefi some rabbit and roasted apple. She vomited, and the 
belly became distended. After remaining in this state for 
fort3'-eight hours, a large alvine evacuation took place from 
the wound; but her strength gradually declined, and she ex- 
pired on the 9th of October. On opening the body, the ab- 
domen was found free from inflammation. The lower part 
of the ileum formed the artificial anus. The large bowel was 
much contracted, and contained only a little mucus. The 
orifices of the intestine were both very small, the lower much 
more so than the upper. 

Who can doubt that the last case would have recovered, 
if it had been properly managed? Had a few more points 
of suture been used, the formation of an artificial anus 
would have been prevented, and nature effected speedy re- 
paration. As it was, the continuity of the tube was inter- 
rupted, and when the external opening became greatly re- 
duced in size, as it did a short time before death, obstruc- 
tion with its whole train of evils was the necessary and inev- 
itable consequence. Even in the first case it is not improb- 
able that recovery might ha\^e taken place, if the divided 
parts had been approximated in such a manner as to prevent 
the establishment of an artificial anus. During the four days 
which the patient survived, every thing she drank passed 
by the preternatural opening, the bowels below remaining in 
the meantime obstinately constipated. It is true the inflam- 
mation might have extended too far before the operation was 
performed, but this is a mere conjecture, and does not invali- 
date the belief that, had the wound been carefully sewed up, 
and the continuity of the canal re-established, restoration might 
have occurred. 

4 * 



122 



Gross on Wounds of the. Intestines. 



3. — Method of Ramdohr. 

This method derives its name from Ramdohr, an eminent 
German surgeon, who flourished at the commencement of the 
last century. It consists in joining together the two ends of 
the divided bowel by introducing the upper within the lower, 
and fixing it there by means of a suture, the extremities of 
which are brought out at the opening in the abdomen. 
Ramdohr, I believe, was the only surgeon who, until recent- 
ly, performed this operation on the human subject; his pa- 
tient, a female, was affected with strangulated cnual hernia, 
and, although he removed two feet of mortified intestine, per- 
fect recovery soon ensued. About a year subsequently to 
the operation she died of an attack of pleuritis, when the 
bowel was carefully inspected, and the two ends were found 
to be beautifully united to each other and to the wall of the 
abdomen. The preparation was sent to Professor Heister, 
of the University of Helmstadt, who preserved it in alcohol,* 
and published an account of it in his Institutes of Surgery. 
To facilitate the invagination, Ramdohr recommends the di- 
vision of a small portion of the mesentery along the con- 
cave surface of the tube, and the insertion of a piece of 
candle. 



*"Et excisa magna intestinorum parte corrupta, binas partes extre- 
mas, easdemque sanas, supei-iori inferiorem insinuata, leniter per in- 
jectum filutn conjunxit. In abdomen reposuit, filique circumducti 
ope ad vulnus abdominis attraxit; atque ita non modo efficit ut cum 
vulnere coiifervesceret, et ad glutinationciii quod mirum videri poterat, 
intestinum divisum perveniret, sod fcminam quaquevelut ex ipsis mortis 
faucibus retraheret, fascibus postea non per vulnus, sed per anum 
rgredientibus. Mulier ilia posta sana vixit; at post annum ex pluritide 
abiit, atque in inciso cadavere intestina divisa inter se rursus coalita de 
preliensa sunt: quin ipsai milii una cum parte abdominis cum qua coal- 
ueruiit, dono dedit; ca que adhuc in spiritus vini asservo, ut dubi- 
tantibus aut discentibus ea semper attendere possim." — Heister, Insti- 
lutiones Chirurgica, T. i., p. 7G8, in 4to. 



Gross on Wounds of the Intestines. 



123 



The objections to this procedure are, first, the impossibility 
of distinguishing the upper from the lower end; secondly, the 
difficulty of effectino; the invagination; thirdly, the tardy and 
imperfect adhesion from a serous surface being placed in con- 
tact with a mucous; and fourthly, the danger of hemorrhage 
from the division of the mesenteric arteries. I shall examine 
these objections in detail. 

The difficulty of distinguishing the two ends from each 
other is always great, if not absolutely impossible. One of 
the most important signs enumerated by authors is the dispro- 
portionate contraction of the inferior extremity. This occur- 
rence, however, although it may occasionally happen, is, 
nevertheless, exceedingly rare, and cannot therefore be de- 
pended upon. I have seldom noticed it in my experiments, 
and the same remark has been made by others. The contrac- 
tion is sometimes more conspicuous in the upper than in the 
lower end, sometimes it is entirely wanting, and in some 
instances it is nearly equal in both divisions. Professor Berard 
of Paris, who was called to a female who had cut out two 
feet of her small bowels, relying upon the certainty of this 
sign, was unwittingly led into the error of inserting the infe- 
rior into the superior orifice, as was shown by the autopsy, 
the patient dying in thirty-six hours.* 

Louis proposed the administration of a small quantity of 
olive-oil, to promote the peristaltic action of the alimentary 
canal. The alvine matter above the seat of the injury would 
thus be evacuated through the superior orifice, and so lead to 
its detection. This is, however, to say the least, a tardy 
and uncertain procedure, and one to which few practitioners 
of the present day would be likely to trust. Where the stom- 
ach is oppiessed, as it almost always is in wounds of tlie 
bowels, with nausea and vomiting, no medicine, however 
mild, would be likely to be retained sufficiently long to pass 
the pyloric orifice. Granting, however, that it might reach 
the bowel, a number of hours would necessarily elapse before 



* London Lancet for 1835-'G, p. 45. 



124 



Gross on Wounds of the Intestines. 



it would produce the desired effect. In the meantime the pa- 
tient would be subjected to the pain and hazard resulting from 
the exposed condition of the protruded visous, which should 
always be returned as speedily as possible; for the longer this 
is delayed the greater will be the risk of severe peritonitis 
and the probability that the patient will die from the shock 
of his wounds. But I need not dwell upon this proposal, as 
it is altogether unlikely that it will be carried out by any 
practitioner of the present day. 

A recent writer, Mons. Jobert, of Paris, observes* that in 
a sphacelated hernia the escape of the intestinal contents 
would show which was the upper end; while, in the case of 
division by a wound, the method suggested by Louis would 
be the best, especially if the oil were mixed with some color- 
ing substance, as syrup of violets or orchanet, "In order to 
distinguish,'' says Professor Cooper, "the upper end of the 
intestine from the lower, the proposal is sometimes made to 
give the patient a little milk, and to observe whether the 
fluid, after a time, issues from the mouth of the protruded 
gut."t 

Some diversity of sentiment still exists in respect to the 
absolute necessity of distinguishing the two ends from each 
other. Jobert thinks it of paramount importance, on the 
ground that if the inferior be inserted into the superior it 
will lead to inversion and obliteration of the tube, followed 
by death from inanition; in proof of which he refers to an 
experiment by himself on a dog in which this result actually 
happened. On the other hand, there is now on record at 
least one example in which the reverse occurred in the human 
subject. Such, at all events is the probability, for as the 
patient recovered no decisive examination could of course be 
made. I allude to the case mentioned by Dr. Pitcher, to 
which I shall hereafter refer in connexion with Ramdohr's 
process, and in which the lower portion of the small bowel 
was inserted into the upper. "I did this," observes Dr. 

•0|). dt. T. i, p. 85. 

t Diet. Surgery, p. 503. New-York edition. 



Gross 071 Wounds of the Intestines. 



125 



Pitcher," because the lower end had been already, by the 
butcher's knife, freed from its connexion with the mesentery, 
in which I found the chief impediment to this mode of junc- 
tion. The peristaltic contractions occasioned by handling the 
bowels embarrassed the operation very considerably, but that 
difficulty was overcome by the manner of passing the liga- 
tures already described."* 

In respect to the difficulty of effecting the invagination 
there is hardly a practical writer that does not fully concur 
in it. It has been already stated, in a previous section, that 
when a bowel is completely divided, there is not only retrac- 
tion of its extremities but also a certain degree of contrac- 
tion, by which the caliber is sometimes diminished one-half 
or even two-thirds, or, rather, I might say, almost entirely 
obliterated. Now any attempt under these circumstances to 
insert the superior end into the inferior, provided it was 
always possible, which, as we have just seen, it is not, to dis- 
tinguish them from each other, would inevitably prove abor- 
tive, unless the parts were most forcibly dilated, and even 
then it would be almost impracticable. Of the truth of this 
abundant evidence has been furnished me by my own re- 
searches, multiplied and repeated as they have been in a great 
variety of ways and in numerous instances. If any further 
proof, however, is needed it is only necessary to refer to the 
experiments of Mcebius, a cotemporary of Ramdohr, and to 
the more recent ones of Dr. Smith and Mr. Travers, before 
adverted to, in which they uniformly failed to accomplish this 
object. "Having divided," says Smith, "the intestine of a 
dog transversely, I attempted to treat it in the manner spoken 
of by Mr. Ramdohr, namely, by introducing the upper ex- 
tremity within the lower; after having procured a piece of 
candle, as directed by him, it was inserted into that portion 
of the intestine which was supposed to be the uppermost. I 
then endeavored to introduce the superior within the inferior, 
but the extremities of each became so everted that it was 
utterly impossible to succeed; it was therefore given up, and 



• American Journal Med. Sciences, vol. x, p. 47. 



126 



Gross on Wounds of the Intestines. 



treated in the way recommended by Mr. John Be]l.* To the 
same import precisely is the testimony of Sir Astley Cooper. 
"Some years ago," he observes,! "I divided the intestine of a 
dog, with a view of trying to introduce the one intestine 
within the other; but I had no sooner made the division than 
the intestines became everted, and so bulbous at each ex- 
tremity that I found it impossible to pass one within the 
other; and that this also takes place in the human subject is 
proved by a preparation of wounded intestine in the Museum 
at St. Thomas' Hospital, taken from a man who had been 
kicked by a horse. The jejunum was ruptured, and it ap- 
pears everted." Such, indeed, must be the experience of every 
practitioner who has had an opportunity of witnessing a 
lesion of this kind, whether in the human subject, or in ihe 
lower animals. 

To overcome this contraction, Professor Velpeau thinks the 
best plan would be to seize simultaneously the two principal 
diameters of the inferior end by their four extremities with 
an equal number of forceps or hooks. Swelling or distention 
of the upper end may be prevented by an assistant holding 
and compressing it, while the operator endeavors to intro- 
duce it into its destined situation'.^ This plan, however, is 
by no means free from objection, since it can only succeed at 
the expense of much pain to the patient, and the risk of crea- 
ting unnecessary inflammation. I have tried it in several 
instances, and this is precisely the conclusion at wliich I have 
arrived. 

The third objection to this proposal is the apposition of a 
serous with a mucous surface. This constitutes no little 
impediment to the reparative process, which can be accom- 
l)lished only after a long time, and then probably in a very 
imperfect manner. Indeed, Mr. Lawrence and others are 
inclined to suppose that direct union cannot be elFected at all 
under these circumstances, asserting that the success depends 



* Inaugural Essay, Caldwell's Collection, p. 296. 
+ Treatise on Hernia, p, 54. London, 1827. 
X Medecine Operatoire, T. iv, p. 134. 



Gross on Wounds of the Intestines. 



127 



altogether upon the extent and firmness of the collateral adhe- 
sions; an opinion which, there is reason to believe, is in the 
main well founded. 

Lastly, the upper part which is to be inserted into the 
lower, must be separated from the mesentery, a procedure 
which sometimes exposes the patient to considerable risk 
from hemorrhage. Of this fact my own experiments have 
afforded me a number of striking and convincing proofs. 
Baron Boyer of Paris, in attempting to put this method into 
execution, tied not less than seven or eight arteries, and yet 
his patient died from effusion of blood into the abdomen. 

Velpeau states that he saw this method tried at the St. Louis 
Hospital of Paris, by Professor Richerand, upon a patient who 
died the following day.* Baron Boyer executed it with no 
better success.f His patient, an athletic brasier, about forty- 
five years of age, had been affected with strangulated inguinal 
hernia for three days, and on exposing the bowel he found 
that it « as mortified. He accordingly made an incision to 
the extent of four inches into the sphacelated part, and thus 
allowed the escape of its contents, to the great relief of the 
individual. The operation over, he administered mild open- 
ing medicines, both to evacuate the alimentary canal, and to 
enable him to distinguish the upper extremity of the gut, 
which, however, was already sufficiently obvious from its dila- 
ted condition. The next day he cut away the mortified 
portion, and united the two ends according to Ramdohr's 
method, introducing the superior, supported by a cylinder 
of card, into the inferior. The operation, however, was not 
only tedious but extremely painful, and when completed, he 
found it impossible to return the gut, distended as it was by 
the foreign body, without a considerable enlargement of the 
ring. The patient grew decidedly worse during this second 
operation; the symptoms of strangulation, which had been 
relieved by the free discharge of ftecal matter through the 



» Op. cit. T. iv, p. 134. 

t Traite des Maladies Chirurgicales, T. viii, p. 134. — Lawrence on 
Ruptures, p. 359. 



128 



Gross on Wounds of the Intestines. 



mortified part, were soon renewed, and destroyed the patient 
in sixteen hours. The dissection revealed inflammation of 
the intestines and a slight efl^usion of blood into the perito- 
neal cavity. 

Flajani, of Rome,* also tried the artifice on several occa- 
sions, but death was invariably the consequence. He experi- 
enced great difficulty in his attempts to invaginate the divided 
extremities of the bowel, and speaks of the practice in terms 
of decided condemnation. 

Notwithstanding these difficulties and disasters, it would 
seem, from the testimony of a recent writer. Professor Vel- 
peau, that Lavielle, Chemery-Have, and Schmidt, have each 
reported a successful example in support of the practice. 
Another, which occurred in our own country, was published 
a few years ago, by Dr. Zina Pitcher of the United States 
army, and, from the manner in which it was treated, reflects 
much credit upon that gentleman. The following is an ab- 
stract of it.f 

Nicholas Miller, a citizen of the Cherokee nation, was 
stabbed on the 22d of June, 1831, with a butcher's knife, which, 
entering the abdomen at the left internal ring, passed up- 
wards and inwards towards the median line, making a wound 
three inches in length in the skin, and another still more ex- 
tensive in the peritoneal sac, followed immediately by a pro- 
trusion of several feet of intestines. The knife had divided 
the ileum diagonally, and se[)arated two inches of the lower 
portion of the mesentery. The fold of intestine in contact 
with this was cut on its convex side two-thirds across; two 
other convolutions were transpierced, and the descending 
colon was partially opened in the direction of its circular 
fibres. Three branches of the mesenteric artery bled pretty 
profusely, and were included in separate ligatures, the ends of 
which were cut olf close to the knots. The extremities of 
the ileum were brought together by passing a needle, armed 



•Collezione d'Osservazioni, &c., di Chiurgia, T. iii, p. 60. Roma, 
f.S02. 

t American Journal of tlie Medical Sciences, vol, .\, p. 42. 



Gross on Wounds of the Intestines. 129 



with a thread, through the upper portion from without in- 
wards, thence into the lower part and out again, including half 
an inch of intestine in the stich, after which it was returned 
through the upper end from within outwards. Three sutures 
of this kind made the inlus-susception complete. The extrem- 
ities of the ligatures were cut off near the peritoneal surface. 
The other openings of the small bowel were closed with the 
continued suture, the ends of which were left long, and so 
tied as to hang within the tube. The wound in the colon 
was united with a single stich. The prolapsed intestines 
were next sponged with warm milk and water and returned 
into the abdomen; a few pieces of the omentum which had 
been injured by the knife were excised, and the edges of 
the outer wound approximated by half-a-dozen turns of 
the continued suture. The external ligatures were detached 
on the fifth of July, and by the eleventh of the month the 
wound in the abdomen was completely healed. 

Lavielle's case occurred at Mainbaste, in the department of 
Landes, in France, and is recorded in the forty-third volume 
of the "Journal General de Medecine." The following notice 
of it is taken from Jobert's treatise on the surgical diseases of 
the alimentary canal.* The patient was affected with ingui- 
nal hernia of the left side, which at length became strangula- 
ted. The tumor was of considerable volume; gangrene super- 
vened, eventuating in the sloughing of the common integu- 
ments, and the effusion of faecal matter. A longitudinal 
incision being made down upon the parts, a coil of intestine, 
a foot long and completely sphacelated, was removed with 
the scissors, when the extremities of the tube were fastened 
to the outer opening with a thread carried through a fold of 
the mesentery. At the expiration of twenty-four hours, 
Lavielle invaginated them by inserting the superior within 
the inferior, and keeping them in contact with the ligature 
previously attached to the mesentery, the ends of which, after 
the replacement of the gut, were brought out at the wound 



* T. i, p. 85. 
5 



130 



Gross on Wounds of the Intesstine. 



in the abdomen. The next day the man walked to the guard- 
house, and continued so to do regularly during the treat- 
ment. The cure was completed in sixty days. 

A.— Method of Le Dran. 

Le Dran was a warm advocate of what is denominated the 
looped suture, of which he was the inventor.* Whether he 
ever employed it in the human subject for purposes of this 
kind, I am unable to say, as I have not before me a copy of 
his works. It is not improbable, however, that he did. To 
perform this suture, as many needles should be used as it is 
intended there should be stitches; they should be round, 
straight, and slender, and furnished each with an unwaxed 
thread a foot long. The lips of the wound being held by the 
surgeon and his assistant, as ma- 
ny ligatures are passed through 
them as may be considered re- 
quisite, with the precaution to 
let the intervals between each 
two of them not exceed a quar- 
ter of an inch. When the su- 
tures are all introduced and the 
needles removed, all the threads 
of one side of the cut are tied 
together at their ends, and then 
those of the opposite side, after 
which the whole are united and 
twisted into a sort of cord. The 
stitches by this procedure are 
approximated to each other, and 
the divided extremities of the 
intestine thrown into plaits, 
by which the edges of the solu- 
tion of continuity are, it is said, 
prevented from gaping. The 
bowel being replaced, the threads are secured to the bandage 




* Traite des Operations Chirurgicales. Paris, 1742. 



Gross on Wounds of the Intestines. 



131 



which is put over the dressing, and the outer wound is closed 
in the ordinary manner. When the injury is sufficiently re- 
paired, which rarely happens under five or six days, the liga- 
tures are untwisted, and all the ends on one side cut off on a 
level with the skin, after which the others are to be slowly 
and cautiously withdrawn. 

The advantages which Le Dran claims for this suture are 
the two following; first, that the twisting of the threads, as 
stated above, produces a slight puckering of the surface of the 
injured bowel, by which the re-union of the edges of the 
wound is more e.ffectually and speedily secured; and secondly, 
that the ligatures may be withdrawn with so much facil- 
ity as not to interfere, in the slightest degree, with the 
adhesive process. These advantages are, it is obvious, alto- 
gether chimerical, for this puckering of the bowel, instead 
of promoting the apposition of the edges of the wound, as is 
contended by Le Dran, has the effect of separating them from 
each other, and thereby increasing the danger of faecal efiu- 
sion. The removal of the ligatures, notwithstanding the 
ease with which it is accomplished, must also have a ten- 
dency to break up the tender adhesions of the part, if not 
to excite undue irritation in the peritoneum. Besides these 
objections, which are in themselves sufficiently serious to 
prevent any future recourse to this method of treatment, 
it is alleged that it is almost always followed by such a dimin- 
ution of the caliber of the alimentary canal as to interfere 
essentially with the passage of its contents. Mons. Velpeau, 
in his Surgical Atlas, has delineated this suture, but whether 
with the design that it should be adopted in practice, or as a 
piece merely of scientific curiosity, I am unable to say. He 
has not made any special mention of it in connexion with 
the subject in his "Medicine Operatoire.'' 

5. — Method of Bertrandi, or '■'■La Suture h Points Passes." 

Another method, which appears to have been a good deal 
employed at one time, was devised by Bertraodi, and is usu- 



132 Gross on Wounds of the Intestines. 

ally described by the French writers under the phrase of "la 
suture a points passes." It differs from the continued suture 
merely in having all the loops laterally, and in drawing to- 
gether only the internal lips of the wound, the outer remain- 
ing apart; or, in other and more simple language, the liga- 
ture is passed through, not over the margins of the solution 
of continuity, as in the common operation. The method of 
Bertrandi has been advocated by Sabatier, Desault, Boyer, 
and several other surgeons, though they have not, I believe, 
adduced any facts in illustration of its efficacy. Boyer says* 
that it possesses the advantage of keeping.the edges of the 
wound together and of promoting their adhesion with the 
surrounding parts, at the same time that it does not occasion 
any puckering of the bowel, or diminution of its caliber; and 
for these reasons he seems to be inclined to give it a prefer- 
ence over other procedures. 

The "suture a points passes" is performed with a round, 
straight needle, armed with a waxed thread. As a prelimi- 
nary step, the surgeon adjusts the edges of the wound, pla- 
cing them parallel and in close contact with each other. 
For this purpose he takes hold of one extremity of it him- 
self, and intrusts the other to an intelligent assistant. The 
needle is then carried somewhat obliquely across the lips of 
the opening, about the fifth of an inch from its extremity: 
having done this it is brought back in the same manner, 
and thus it is passed alternately from one side to the other 
until the whole track is closed up, the operation being simi- 
lar to that employed by a tailor in sewing together two 
pieces of cloth. The interval between the respective stitch- 
es should not exceed two lines, or the sixth of an inch, 
otherwise fa>cal matter may escape into the abdomen. The 
intestine being replaced, the extremities of the suture are 
brought out at the external opening, where they are secured 
by a strip of adhesive plaster. In a few days one of them 
should be cut off close to the wound, and the other gently 



• Maladies Chirurgicales, T. 7, p. 379. 



Gross on Wounds of the Intestines. 



133 



pulled to promote its separation. Some of the successors 
of Bertrandi recommend that the ligature should be passed 
through the edges of the outer orifice, to prevent the bowel 
from slipping out of the reach of the surgeon; a precaution 
which can only be necessary when the patient is very young 
or restless. 

To obviate the danger of destroying the feeble and imper- 
fect adhesions of the intestine, incurred in withdrawing the 
suture in the manner suggested by Bertrandi, it occurred 
to Beclard that it might be advantageous to use two liga- 
tures, one white, the other colored. The mode of per- 
forming the operation does not differ in other respects from 
that which we have just described. When the time for re- 
moving the threads has arrived, the surgeon withdraws them 
in opposite directions, taking hold of the white one, for ex- 
ample, with the left hand, and of the colored with the right. 
The result of this traction is that the adhesive process is 
scarcely at all disturbed, while the reverse must always 
happen when the suture is detached in the manner recom- 
mended by Bertrandi. 

With the exception of Boyer, I do not tnow that the 
method of Bertrandi has any advocate at the present day. I 
have not tried it upon any of the inferior animals, and we 
are not in possession of any facts which warrant its employ- 
ment in the human subject. 

6. — Method of the Four Masters. 

The method of the four masters — "Quatre Maitres" — as it 
is termed, which is usually attributed to Duverger, who was 
the first to revive it after it had fallen into neglect, consists 
in stitching the divided ends of the bowel over a piece of 
trachea, either of the calf or of some other animal. What 
the precise length of the tube was I am unable to say, but in 
all probability it did not exceed two inches. In its diameter 
it was a little smaller than the alimentary canal, into 
which it was intended to be introduced, and previously to 
5 * 



134 



Gross on Wounds of the Intestines, 



using it it was well dried and varnished, to prevent it from 
too readily imbibing moisture. Tliree ligatures were passed 
through it equidistant from each other, and armed each with 
a small curved needle. The piece of trachea thus prepared 
was inserted into the ends of the bowel, where it was secured 
by three interrupted sutures made by passing the needles 
from within outwards, about three lines from the edges of 
the wound, which were held together by an assistant. The 
ends of the threads were cut off close to the knots, and the 
parts reduced by pushing the lower end in first. 

This method of the four masters is said to have been suc- 
cessfully employed by Duverger in a case of strangulated 
hernia, in which a part of the bowel was affected with gan- 
grene.* In the account of this process, as given by Dupuy- 
tren, in his Treatise on Gun-shot Wounds, f the inferior ex- 
tremity is directed to be drawn nearly half an inch over 
the superior, placing thus, as in the operation of Ramdobr, 
a mucous surface in contact with a serous. The surgeon, 
also, is made to use a single suture, instead of three, as sta- 
ted above, and the upper end of the gut is to be careful- 
ly distinguished from ti)e lower. 

This method, slightly modified, was successfully employed 
by Sir Astley Cooper upon a dog. He used a cylinder of 
isinglass instead of a calf's trachea, upon which he made 
three sutures, one at the mesentery, and another at each side of 
the bowel, which was then returned into its natural situation. 
In three days the animal took food, had regular stools, and 
on the sixteenth day he was killed, when the united parts 
were shown by Sir Astley to his students. No advantage 
appeared to result from the cylinder of isinglass, as it be- 
came shut by the contraction of the intestine, and the experi- 
ment was therefore never repeated. t 



' Diet, de Med. et de Chir. Pratiq., T. 13, p. 267. 

\ T. i., p. 194. 

\ On HerDia, p. 51. 



Gross on Wounds of the Intestines. 135 



Sabatier proposed, as a substitute for the piece of trachea, 
recommended by the four masters, a roll of paste-board, 
which he advised to be well varnished with oil of turpentine, 
or some other tenacious fluid, and fastened to the bowel with 
a single stitch. Watson, an English writer, speaks favora- 
bly of a canula of isinglass. Some of the older surgeons 
were in the habit of employing a tube of elder-wood; 
others a piece of tallow candle. Rogers, Gamier, and The- 
odore recommend the use of the elder-wood to defend the su- 
ture from the injurious effects of the faecal matter, of which 
they appeared to have much dread. 

The method of the four masters, somewhat modified, is 
warmly advocated by Chopart and Desault, in their Treatise 
on Surgery. The improvement which these two distinguished 
men suggested, but which was never, I believe, carried 
into effect by them upon the human subject, consists in pass- 
ing two fine needles, armed with a silk ligature, twelve 
inches long, through the centre of the paste-board cylinder, 
and bringing them out respectively three lines above and be- 
low their place of entrance. The ligature will thus be found 
to be attached to the artificial tube, without crossing its cavi- 
ty, or interfering in any wise with the transmission of faecal 
matter. The two needles are next carried through the upper 
part of the bowel, equidistant from each other, and at a 
point from the wound equal to the half of the length of the 
cylinder. The latter is now to be engaged in the upper por- 
tion of the intestine, after which the lower end is to be 
pierced in the same manner, but a little farther from the seat 
of the injury, and the remainder of the tube to be introduced 
along with five or six lines of the inferior extremity of the 
gut. Should this invagination be attended with much difficul- 
ty, on account of the mesentery, the latter should be detached 
to the requisite extent, and the operation finished in the man- 
ner already stated, care being taken to tie any obstinately 
bleeding vessels. The parts, when returned, should be kepi 
in exact apposition with the external wound, to promote 
their adhesion, an object which may be readily accomplished 



136 Gross 071 Wounds of the Intestines. 

by securing the ends of the ligature to the surface of the ab- 
domen.* 

7. — Method of Pa/Jin, Bell, and Scarpa. 

J. Palfin, author of the "Anatomic Chirurgicale," thought 
it of much less importance to sew up the wounded intestine 
than to stitch it to the wall of the abdomen. In conformity 
with this belief he advises the surgeon to carry a waxed 
thread, armed with a needle, through the edges of the solu- 
tion of continuity at their centre, and after tying it into a 
simple slip-knot, to bring the ends out at the external open- 
ing, where they are to be secured by an adhesive strip. He 
entertained the singular notion that the divided ends never 
united with each other, but that the cure was effected solely 
by the adliesions which they formed to the surrounding parts. 
This plan, which certainly possesses the merit of great 
simplicity, he considered as equally applicable to transverse 
and longitudinal wounds, t 

This method of the old French surgeon found a warm ad- 
vocate in that great luminary of the profession, the late Mr. 
John Bell, who, however, does not appear to have been 
aware that it had been previously recommended; at all events, 
he has not any where alluded to Palfin or his writings in con- 
nexion with the subject. Like his Gallic predecessor, he 
suggests that only a single stitch should be taken, and .that 
the thread should be brought out at the external opening; 
adding, in his own expressive language, that if there be in 
all surgery a work of supererogation it is this operation of 
sewing up a wounded gut. J This plan he advises not only 
where there is a simple slit-like aperture in the bowel, the 



• Tavcrnier's Operative Surgery, translated by the author, p. 276. 
Phila. 1829. 

t Anatomie Chirurgicale, T. ii, p. 7G. Paris, 1743. 
I Discourses on the Nature and Cure of Wounds, vol. ii, p. 80. 
Walpole, N. H., 1907. 



Gross on Wounds of the Intestines. 



137 



kind of injury most commonly met with, but where it is 
divided in its entire cylinder. He is of opinion that it is 
only necessary to keep the wound of the intestine neatly and 
closely in contact with that in the wall of the abdomen, 
when the parts will gradually adhere, affording at the same 
time an opportunity for the escape of faecal matter. He con- 
tends that sewing up the breach in the intestine firmly with 
a needle and thread is absurd, and that the mere pressure up- 
on the abdominal viscera will keep the edges of the wound 
so close to the peritoneum as to insure their re-union. But 
is this the practice generally pursued by surgeons, or, 
rather, is it not universally abandoned, for the sufficient 
reason of its entire inadequacy? If there ever was an er- 
ror committed by any writer more serious, culpable, and 
mischievous than another, it is most assuredly this of Mr. 
John Bell, who while criticizing and condemning, in no 
measured terms, the advice and practice of others, has him- 
self fallen into a most strange delusion. Had he performed 
the operation in a single instance upon the human subject, or 
upon an inferior animal — an experiment from which he alfects 
so much to shrink — he would have become fully sensible of 
its danger and insufficiency. That the operation, as recom- 
mended by this eminent surgeon, might occasionally be at- 
tended with success is not improbable, but that it should not 
be trusted to in the present enlightened state of the healing 
art must be obvious to all who will be at the trouble to in- 
vestigate it. Independently of the great risk of faecal effu- 
sion into the peritoneal cavity, there are few cases, if any, 
in which it would not be followed by an artificial anus, an 
occurrence which need never attend enteroraphy when per- 
formed in the manner previously pointed out. 

Although both Smith and Travers had already exposed the 
insufficiency of this mode of procedure, I was determined, 
if possible, to throw additional light upon it, and with this 
view instituted several experiments, the results of which, as 
will be here seen, fully confirm those of the above investi- 
gators. 



138 



Gross on Wounds of the Intestines. 



Experiment I. — Having obtained a small slut, a fold of the 
ileum was drawn out of the abdomen, and divided through 
its entire cylinder. A single stitch was then carried through 
the everted edges, at the point opposite to their attachment 
to the mesentery, when the ends of the ligature were tied 
and left protruding at the external orifice, which was secured 
in the usual manner. In thirty-five hours the animal expired, 
having in the meanwhile suffered severe pain and refused 
such food as was offered her. The opening of the abdomen 
was followed by the escape of a considerable quantity of fce- 
tid gas; and the peritoneal sac, which exhibited marks of 
high inflammation, contained more than an ounce of fluid and 
solid faeces. The edges of the wound were red, besmeared 
with thick and ropy mucus, and at least three lines apart at 
the widest portion of the breach. No attempt at reparation 
was visible. 

Experiment II. — The above experiment was repeated upon 
a small but full-grown dog, which died in twenty-four hours 
after the operation. A considerable quantity of thin alvine 
matter was found in the abdomen, as in the preceding case, the 
peritoneum was extensively inflamed, several coils of intes- 
tine adhered slighly to each other, and the lips of the wound 
were deeply injected, with marked eversion of the mucous 
membrane, but no incrustation of plastic lymph. It is wor- 
thy of remark that, neither in this nor in the preceding expe- 
riment, was there any discharge of faeces through the exter- 
nal wound. 

Experiment III. — A young dog of moderate size was sub- 
mitted to the same experiment as the two preceding, with 
this difference, that the incision passed only through two- 
thirds of the intestine, producing a wound about an inch and 
three-eights in extent. For the first twenty-four hours he 
was apparently well, being lively and cheerful, but afterwards 
symptoms of indisposition came on, and he died early on the 
third day. The lips of the wound, red and injected, were 
separated fully a line and a half at their middle; semi-fluid 
fajces with some water which the animal had drank, had 



Gross on Wounds of the Intestines. 



escaped into the abdomen, and the peritoneum, especially in 
the vicinity of the injury, displayed strong marks of inflam- 
mation. The external wound had a red angry appearance, 
from the passage, no doubt, of fajculent matter, which was 
discharged through it for ten or fifteen hours before death. 

In an experiment of this kind performed by Mr. Travers,* 
the animal survived only a few hours. The peritoneum ap- 
peared highly inflamed, adhesions existed among the neigh- 
boring folds, and lymph was deposited in masses upon the sides 
of the injured gut. A quantity of bilious fluid was found 
among the abdominal viscera together with some other extran- 
eous substances, and a worm was depending from one of the 
apertures of the gut, which had receded to the utmost and 
were of a circular form. 

Tn three experiments by Dr. Smithf instituted with a view 
of ascertaining the merits of Mr. Bell's treatment, one of the 
dogs died at the end of the first day, the other on the fifth 
day, and the third on the seventh day. In all, the intestines 
were very much inflamed, from the eflTusion of faecal matter 
into the peritoneal sac. In one of the animals, that namely 
which lived longest, one part of the injured intestine had 
contracted adhesions to the external wound, allowing thereby 
a slight discharge of fa3ces in that direction. 

Thus, in seven experiments, all conducted, there is reason 
to believe, with the requisite care and skill, not a single one 
had a favorable termination. Nor is this surprising when we 
consider the circumstances which invariable attend lesions of 
this description; we have already seen that punctures of the 
bowel, more than a third of an inch in length, are almost con- 
stantly followed by faecal extravasation, and the same 
thing it will be recollected is apt to happen in more ex- 
tensive wounds treated with the interrupted suture, when 
the interval between each two respective ligatures exceeds 
three or four lines. That Mr. Bell should have committed 



*0p. cit., p. 116. 

t Caldwell's Medical Theses, p. 296. 



140 



Gross on Wounds of the Intestines. 



such an error is not to be wondered at when we remember 
the period at which he wrote: he instituted no experiments 
on any of the inferior animals to elucidate the subject, and 
the beautiful researches of Travers, Thomson and Smith had 
either not been made, or no notice of them had appeared. 
He sinned, therefore, because he had not the requisite light 
to guide him. But it is otherwise with Professor Cooper, of 
London.* In sanctioning, as he does, the practice of John 
Bell, he is instrumental in perpetuating an error for which 
modern surgery can find no excuse, and which deserves to be 
reprobated in the strongest terms, from the pernicious ten- 
dency which it must exert upon the younger members of the 
profession when inculcated by an authority so respectable and 
influential. 

Professor Gibson, of Philadelphia, appears to be disposed 
to advocate the same kind of practice. f "Should a case pre- 
sent itself" says he, "which, from the extent of the wound 
and other circumstances, seemed to require a suture, I should 
be inclined to follow the plan of Mr. Bell, and simply employ 
one or more tacks of the interrupted suture, merely for the 
purpose of connecting the wound in the gut slightly to the 
external wound." 

Still more extraordinary and unaccountable is the plan of 
procedure proposed by Professor Scarpa, of Italy.J This 
celebrated surgeon has offered a variety of arguments against 
sewing up the wound at all, and asserts that in all cases of 
injury of the intestinal canal, whether the opening be longi- 
tudinal or transverse, a suture is always not only useless, but 
even dangerous and fatal. Great evils, he thinks, arise from 
the passage of the ligatures, however few, across the delicate 
and sensitive tunics of the bowels, which are thus exceedingly 
apt to become inflamed, and to propagate the morbid action 
rapidly to the surrounding viscera. He affirms that the expe- 

• First Lines of Surgery, vol. ii, p. 74. 

t Institutes of Surgery, vol. i, p. 119. 1838. 

\ Treatise on Hernia, translated by Wishart. — Cooper's First Lines 
of Surgery, vol. ii, p. 71. 



Gross on Wounds of the Intestines. 



141 



rience of several ages clearly proves that nearly all who have 
been subjected to enteroraphy have died in the severest 
agony, and that the few who have recovered have escaped, 
not in consequence of the operation, but in despite of it. I 
do not deem it necessary to enter into any formal refuta- 
tion of these singular views of the illustrious professor of 
Pavia. I must only express my surprise that they should 
have been entertained and promulgated after the publi- 
cation of the researches of Mr. Travers, which shed so 
much light upon the subject, and so emphatically incul- 
cate the indispensable importance of the suture in all wounds 
of the intestines, even when of comparatively small extent. 
It is one of those remarkable circumstances which not unfre- 
quently occur in our profession, and which can only be ex- 
plained by a reference to the infirmities and prejudices of our 
nature. The case of Scarpa is on a par precisely with that 
of John Bell. When this eminent surgeon was at such pains 
to criticize and condemn the practice of his name-sake, Ben- 
jamin Bell, of Edinburgh, in regard to the present topic, he 
had probably little idea that the verdict of the profession 
would, in less than a quarter of a century, entirely reverse 
his decision, and treat him as unsparingly as he did his Scotch 
cotemporary. 

(To be continued.) 



6 



iJtfjUoflrapftfcal Notices. 



Art II. — The Climate of the United States and its Endemic 
Influences. Based on the Records of the Medical Depart- 
ment and Adjutant GeneraVs Office, United States Army. 
By Samuel Forry, M. D. 

L' ensemble de toutes les circonstances naturelles et physiques, 
an milieu desquelles nous vivons dans chaque lieu. — Cabanis. 

The best observations upon climate often lose half their value 
for the want of an exact description of the surface of the 
country. — Malte-Brun. 

New York: J. ^ H. G. Langley, 57 Chatham street; Barring- 
ton and Haswell, Philadelphia; Little and Brown, Boston, 
1842, p. 378 12mo. 

In respect to works of its own class, this volume may be 
regarded as the book of books — or it might be called the 
book — there being, as far as we are informed, no production 
resembling it, either in the English, or any other, language. 
Assuredly there is none strongly resembling it; much less is 
there any one equal to it, in many of its most interesting and 
important qualities. It is therefore not only original, but 
unique in its kind. 

To characterize it still further, it is the first work written 
on the subject of general American medical statistics, and is 
therefore, in its object entirely new. Its basis is spacious. 



Forry on the Climate of the United States. 143 



being co-extensive with the outline of the United States; its 
matter consists of facts of great value, collected by observa- 
tion continued, with uncommon labor, perseverance, and 
pains-taking, through a period of tioenty years; these facts 
are composed of the manifold and important elements that 
enter into the composition of the different climates of the 
United States, and the effects, salutary and deleterious, which 
those climates produce on organized matter; and of the changes 
which the climates have already sustained, since the settle- 
ment of the country, and are still sustaining, by the action of 
certain specified causes. And to all this is added much infor- 
mation, curious as well as useful, respecting the changes and 
their effects, that have occurred in the climates of other coun- 
tries, within the period of historical records. 

Nor, are these facts, interesting and valuable as they are, 
all that confers on the volume its title to the high standing 
it is destined to attain. Far from it. The excellence of 
its plan and arrangement, the elevation and even grandeur 
of its aim, the masculine spirit and love of philosophy 
which pervade it, and the elegant style in which it is com- 
posed, are in no respect inferior to the matter which it con- 
tains. 

Should any one competent to sit in judgment on this pro- 
duction suspect us of bestowing, in these expressions, undue 
commendation on it, let him attentively study it, and he will 
be made sensible of his mistake. We say, "study it;" for the 
whole amount of its worth is not to be fully apprehended and 
weighed by a common-place perusal of it. 

But we have not yet mentioned the special purposes which 
our author had in view in the preparation of the work. That 
our readers therefore may have a knowledge of them the 
more exact and definite, we shall state them in the writer's 
own words. 

"The chief objects intended to be accomplished by the 
publication, are to present, in Part First, a classification of 
the principal phenomena of our climate, physically consider- 
ed; and to attempt in Part Second, to trace out the medical 



144 



Forry on the Climate of the United Stales. 



relation af these laws, thus establishing in both a classifica- 
tion of climates having for its basis observation." 

Jn more detailed, and perhaps more communicative lan- 
guage, the design of our author is, to point out to what ex- 
tent, and by what agents, climate (including, as two of its 
elements, special and influential localities, and given geologi- 
cal formations) is instrumental in the production of such com- 
plaints as prevail epidemically in difierent situations. And 
it will not be denied, that the object thus held in view by 
him constitutes one of the weightiest and most interesting 
desiderata connected with the medical literature of our coun- 
try. And the ability, with which he has executed his design, 
places, in that respect, the medical literature of the United 
States above that of any or all of the nations of Europe. 
For, as already mentioned, we have yet to learn that a single 
work of the kind has heretofore appeared, in any language, 
comparable to that which now lies before us. And we are 
gratified to learn that, in this sentiment, some of the Euro- 
pean Journals fully concur, and, with that liberality and mng- 
nanimity, which should always cbaracteriie scientific produc- 
tions, avow that concurrence. 

We know of only three persons who have heretofore made 
the climate of the United States a subject of discussion to 
such extent as is worthy of notice. But they were men of 
great knowledge, ability, and distinction — Mr. Jefferson, Dr. 
Rush, and Mr. Volney. For want of an acquaintance how- 
ever with certain branches of knowledge indispensable lo 
their purpose, neither of them was qualified for tlie Jask he 
undertook. The reason is plain. Neither of them was versed 
in either meteorology or geology, and, of the three, Dr. Rush 
alone was acquainted with medicine. And, as a qualification 
for a thorough discussion of the subject of climate (such dis- 
cussion we mean as that we are now noticing) a knowledge 
of those three branches of science is essential. And L r. Forry 
has shown that his qualifications in those and all other re- 
spects, are amply sufficient for the accomplishment of the 
enterprise in which he engaged. 



Forry on the Climate of the United States. 



145 



With such qualifications, united to the persevering labor 
he bestowed on the subject, the result corresponds. Not only 
has he shown himself to be far superior to his three distin- 
guished predecessors in the amount, but also in the accuracy, 
of his knowledge of the climate of the United States. Hence 
he has satisfactorily corrected sundry errors which they had 
committed; and by which, through the influence of their 
writings, and the weight of their names, the public mind has 
long been misled. Dr. Forry moreover has manifested in his 
treatise as much of sound judgment and practical common 
sense, as he has of an acquaintance with letters, and with the 
principles of the several branches of science, to the study of 
which he has so successfully devoted himself. If we mistake 
not, such will be the standing and effect of the work from his 
pen, which we are now considering, that it will be instru- 
mental in producing, at least among his countrymen, if not 
on a more extensive scale, the commencement of a new era 
in the cultivation of climatology. Our author's definition of 
climate alone is indicative of his entire mastery of the sub- 
ject. He has given a much more thorough and comprehen- 
sive exposition of it as an aggregate, as well as a more full 
and accurate detail of the elements which compose it, than is 
to be found in any other work, with which we are acquainted. 
That our renders may examine and judge of it for themselves, 
and derive from it the information it is calculated to impart, 
we shall present them with the passage containing the defi- 
nition: 

"The term climate, which is limited, in its rigorous ac- 
ceptation, to a mere geographical division, and in ordinary 
parlance, to the temperature only of a region, possesses in 
medical science, a wider signification. It embraces not on- 
ly the temperature of the atmosphere, but all those modifica- 
tions of it which produce a sensible effect on our organs, 
such as its serenity and humidity, changes of electric tension, 
variations of barometric pressure, the admixture of terrestrial 
emanations dissolved in its moisture, and its tranquility as 
6 * 



146 Forry on the Climate of the United Slates. 



respets cboth horizontal and vertical currents. Climate, in a 
word, as already defined, constitutes the aggregate of all the 
external physical circumstances appertaining to each locality 
in its relation to organic nature. "To observe," says Pro- 
fessor Rostan, "the simultaneous effects of light, heat, elec- 
tricity, of the winds, &c., on the organic productions of the 
different zones of the earth, to explore the nature of this 
earth, to deduce from this knowledge the influence which 
they exercise on the physical and moral nature of man, such 
is the wide field which climates present to investigation." 

We have said that our author's mind is judicious and prac- 
tical, no less than scientific and literary. In illustration 
and proof of this, it is necessary for us only to say, that his 
application of climate, as just defined, to the promotion and 
preservation of health, the production and modification of 
disease, and of course to the furtherance of the public good, 
is in strict accordance with his views of its composition and 
nature, as an agent, exercising an influence on organized mat- 
ter. Hence his division of the United States into three great 
compartments — the Northern, Middle and Southern — in each 
of which the diseases that prevail correspond to the predomi- 
nant elements of the climate of the place, in full and fair 
correspondence with his representation of them. In further 
explanation of our meaning on this topic, we shall extract 
from his publication another passage. 

"The connexion between meteorology and medical science 
is, in truth, highly important. From the days of Hippocra- 
tes, the records of medical philosophy demonstrate that the 
phenomena of life are not the result of original organization 
only; but that the moral, intellectual, and physical capacities 
of man are subject to the influences of those causes, the ag- 
gregate of which constitutes climate. The doctrine receives 
an apposite elucidation in the corporeal degeneration induced 
by malaria. So deep and pervading are the effects of this 
subtle poison on the indigenous inhabitants of marshy dis- 
tricts, in warm climates, that the energies of the system are 
sapped, and premature decrepitude induced; and when sub- 



Forry on the Climate of the United Stated. 



147 



jected to these baneful exhalations, through successive gene- 
rations, the mind becomes torpid and imbecile, the moral 
sentiments debased, and the stature and symmetry of the 
body deteriorated. Again it finds a ready illustration in the 
history of the recent epidemic (cholera asphyxia) which, 
in its wide diffusion, threatened to depopulate vast tracts of 
the earth's surface; but which, owing doubtless to great me- 
teorological changes, notwithstanding inappreciable by our 
eudiometric instruments, suddenly ceased its ravages, and 
left, like many other destructive pestilences in preceding 
ages, scarce a trace behind but the terror of its name." 

It is perhaps due from us to our author that we say some- 
thing more definite and characteristic, than we have yet done, 
of his style, to which we do no more than justice, when we pro- 
nounce it eminently spirited, graphic, and scholar-like. In 
one extract more it shall speak for itself; in doing which it 
will testify conclusively to the correctness of our remark. 

"But woe to the invalid that braves the torments of a 
summer residence" (in a burning climate,) "under the dis- 
advantage of a camp life! Insects are the pests of a tropi- 
cal clime. As to fleas, flies, and ticks, the interior of Flori- 
da may well rival Egypt in the days of Pharoah. The chi- 
goe (pulex penetrans) insinuates itself beneath the skin, 
where it soon establishes a populous colony. Flies seem 
indeed to form a component part of your food, your drink, 
and the atmosphere you inhale. Lizards, snakes, and scor- 
pions get into your bed, whilst the industrious ant and weevil 
not only eat your rations, but devour your books — the food of 
the mind. All nature seems alive; and every hour you ob- 
serve some uncouth living thing, whose family name has 
scarce been registered by the entomologist. In addition to 
these annoyances, the ear will be greeted by a nightly sere- 
nade performed by wolves and alligators — a woful concert of 
whining yells and dismal bellowings, constituting the reali- 
zation of a holding wilderness." 

JNotwiths landing however the high estimation, in which 
wc hold the work before us, as a whole, there are certain 



14S Forry on the Climate of Ihe United States. 



positions in it, in which our own observation, connected 
with reflection, forbids us to concur. We shall briefly state 
two of them, both of which relate to winds. 

We believe and have long believed with Dr. Forry, that 
the Gulf-stream and the immense "ocean-lake" which it 
forms, expend much — perhaps most of their tepefying influ- 
ence on the atmosphere of the northern and eastern Atlantic, 
and on that of the western shores of Europe and Africa. 
For that Africa as well as Europe feels that influence, can- 
not vve think, be reasonably questioned. 

We are strongly apprehensive, however, that the climate 
of the United States is more affected by the Gulfstream, 
than the Doctor seems fully prepared to admit. This is the 
case, in particular, during the prevalence of a strong east, or 
southeast wind. The latter wind more especially throws, in 
few hours from its commencement, the whole mass of the 
Gulf-stream atmosphere on the shore of the States to which 
it is directed. 

This wind, when it begins to blow, is comparatively coo/; 
because it brings with it the temperature of ihe ocean-atmos- 
phere between the Gulf-stream and the American coast. But 
in the space of from three to five hours, and sometimes less, 
it i)ecomes warmer by several degrees; because it then pos- 
sesses much of the temperature of the atmos]ihere of the 
Gulf-stream. We might say tliat it is then nothing but a 
current of that atmosphere setting toward the west. Thus 
is the climate of our eastern border rendered holter by it in 
summer, and milder in winter. It is worthy of remark hovi'- 
ever, that, during the latter season, south-easters are rare with 
us. 

The same wind moreover is often, if not usually, instru- 
mental in the formation of clouds, which descend ft»r the 
most part in torrents of rain. The reason of this is plain. 
The warm air comes loaded with humidity from the ocean, 
which, when sufficiently condensed, by the coolness of the 
land-air, assumes, by attraction, the shape of water-drops, 
and falls, by gravity, in the form of rain. So much for the 



Forry on the Climate of the United States. 149 



south-east wind. Now for a few remarks on its antago- 
nist. 

The north-west wind is the coldest that is experienced in 
the United States. The reason of its low temperature, as 
Dr. Forry and most if not all other persons allege, is, that it 
conies from the cold atmosphere of what is usually called the 
"American Tartary," far beyond the region of the Lakes. 

In this hypothesis we cannot concur; because we believe 
it groundless and untenable. In our brief discussion of it, 
we shall express ourselves as if resident in the city of Phila- 
delphia, because we there first made it a subject of examina- 
tion and thought. We therefore now consider ourselves re- 
mote from the frozen and snow-covered plains of the Ameri- 
can Tartary, at least from fifteen hundred to two thousand 
miles — we believe much more. 

No wind short of a hurricane travels Jifty miles an hour. 
The north-west wind rarely travels more than from twenty 
to thirty. But we will give it the rate of /or/y, which we 
know to be not a little beyond its usual velocity. On the 
supposition that its starting point is distant from us two thou- 
sand miles, it will reach us in fifty hours — and if only fifteen 
hundred, in a few minutes more than thirty-seven hours. 

Nearly that space of time then must elapse, after the com- 
mencement of the north-west wind, before it can reach us in 
Philadelphia, and cool materially the temperature of the 
atmosphere. 

But is such the case? Does a period of that extent pass 
by, before the frigorific influence of the wind is experienced? 
Far from it. N^ota tenth of the space expires before its effect 
is very sensibly, not to say severely felt. 

We have witnessed a depression of the mercury, by the 
chilling action of the north-west wind, to the extent o{ thirty 
degrees, in less than three hours. We once at least, if not 
oftener, knew a change of the kind to be produced, in very 
little more than one hour. 

From the region far north and west of the lakes then, it is 
absolutely impossible for that cold wind to come. We deem 



150 Forry on the Climate of the United States. 



il highly questionable, whether a wind of such extent has 
ever existed. A stream of air, over mountains and hills, two 
thousand, or even fifteen hundred miles long, would be, we 
apprehend a new phenomenon. The areas of such atmospheric 
movements are usually limited. Mariners know that ships at 
sea but a day's sail from each other, or perhaps less, where 
there is nothing to obstruct the sweep of the air, often experi- 
ence at the same moment very different weather While one 
is in a gale, its neighbor is becalmed. We once sailed from Lon- 
don, in company with an American ship, bound like ourselves 
to the United States. So great was our superiority in sail- 
ing-speed, that, in a few hours, we left our companion nut of 
sight behind us. Yet she made her passage, under fine wea- 
ther and fair winds, in about twentyfive days; while xoe, pur- 
suing a track not very distant from hers, were detained on 
the water by heavy gales, head-winds, cross-winds, and no 
winds at aW, fifty -two days. Nor are events of the kind unu- 
sual. 

Whence then, it be may asked, does the north-west wind 
come? It appears and has long appeared to us to come from 
above, in such an earthward direction, as to bring down with 
it the higher and colder strata of the atmosphere, whose tem- 
perature is at, or perhaps below the freezing point, and min- 
gle them with the lower and warmer strata, thus reducing 
the latter to a medium temperature. 

Are we asked, why we believe that the north-west wind 
comes to us in a direction more perpendicular than that of 
other winds? We reply, that the phenomena attending it 
appear to us to testify strongly to that effect. It makes our 
chiranies smoke much more certainly and annoyingly than 
any other wind. It even rushes very often directly down the 
chimney, blowing soot, smoke, and ashes out of the fire- 
place. Nor is this all. It comes in puffs and flaws, which 
render it unusually dangerous to sail-boats. While other 
winds make their approach horizontally, producing a ripple 
on the water, which warns the boatman to be on his guard; 
it pounces on him from above, like an eagle on its prey, and 



Forry on the Climate of tka United States. 



151 



not unfrequently capsizes his wherry. Previously to the con- 
struction of steam-vessels, three-fold more ferry-boats were 
upset, on the river Delaware, by the north-west wind, than 
by those from all other points of the compass. 

The opinion here expressed respecting the source of the 
coldness of the north-west wind, we have entertained and 
defended almost from our boyhood; and we published it early 
in the present century, accompanied by the reasons which 
we deemed confirmatory of it. And though we do not pro- 
nounce it incontestable, yet, as far as we are informed, it has 
never been contested. One word more before we dismiss it. 

M. Volney inserted the opinion in his treatise on the cli- 
mate of the United States, and considered it well-founded 
and sound. In thus stating it, and sanctioning it by his name, 
he made no reference to us. Yet we solemnly declare, that 
he was indebted for it to us; though we were quite youthful 
at the time. Nor is this the only opinion that M. Volney 
borrowed from Americans, and inserted in his book, without 
acknowledgment. In truth, though extensively informed, he 
was a plagiary — and not an original either in observation or 
thought. 

Are we again asked, why it is that the north-west wind 
should come to us, in a direction more perpendicular, than 
that of any other wind? We reply that we do not know. 
But our ignorance of the cause detracts in no degree from 
either the possibility, or the probability of the fact. We do 
not belong to that class of wise ones, who discredit facts, 
merely because they do not and cannot comprehend their 
causes. When we look thoroughly into the matter, facts are 
the only objects of our knowledge. Of causes, whether 
moral, intellectual, or physical, and of their mode of opera- 
ting, we are perfectly ignorant. On the present subject 
analogy may throw some semblance of light. At least it may 
make it appear, that a wind pursuing a downward direction 
is neither an unnatural nor a preternatural phenomenon. 

It is well known that down the sides of the Andes, the 
Alps, the Pyrenees, and other lofty and snow-covered moun- 



152 



Forry on the Climate of the United States. 



tains, streams of cold air frequently descend into the vallies 
at their feet, suddenly and greatly reducing the temperature 
of their atmospheres. Nor do these cold winds pass over 
the tops of mountains, and then sweep downward along their 
sides. They come from their lofty regions, but not from their 
tops. Yet we know not why the air thus descends. But we 
know the fact, and confide in its truth. And we further 
know, that when a wind passes over the top of an elevated 
mountain (which it sometimes does) it pursues a down- 
ward direction, along its opposite side. In truth there is 
no other direction which it can pursue. A downward wind 
therefore is not prohibited by the laws of nature. Nor can 
we render any reason why a stream of cold air may not 
descend through the atmosphere in other places, as well as 
down the inclined plain of a mountain. 

Another phenomenon connected with our subject may be 
cited. Every tornado, violent thunder-storm, and other fierce 
commotion in the asmosphere, diminishes its temperature. 
And this effect it produces by mingling together the higher 
and lower strata of air. 

Though these remarks do not solve our problem, respect- 
ing the perpendicular direction of the northwest wind, they have 
a t-endency to render it more familiar to us — and also the 
more to persuade us perhaps of its probability. At any rate, 
no hypothesis can be devised more perfectly groundless — 
assuredly not more improbable, than that which transports 
the cold of a northwester to the coast of the Atlantic, and 
even hundreds of leagues along its surface, from the frosty 
atmosphere of a country far beyond the lakes. 

But we must bring to a termination this notice, vvhich, 
though longer than we designed to make it, has disclosed but 
a mere fraction of the value of the volume we have been 
considering. Of even the leading elements of it, to which 
it was our intention to refer, we have been able to embrace 
in our remarks but a few. In truth, as already intimated, 
the entire and abundant amount of that value can be com- 



Forry on the Climate of the United States. 153 

passed only by a thorough acquaintance with the production 
which exhibits it. As that production, however, merits, as 
highly as any other of American origin, instead of a mere 
notice like the present, a full, regular, and well prepared 
review, it may perhaps be treated by us somewhat to that 
effect in a future article. Meantime we earnestly recom- 
mend it to the attention and study of such readers, as covet 
at once high gratification and important instruction. 

C. C. 



THE WESTERN JOURNAL. 



Vol. VIL— No. II. 



LOUISVILLE, FEBRUARY 1, 1843. 



We publish the following communication with great pleasure, 
since it affords us an opportunity of introducing to the profession one 
of the most accomplished young chemists in our country. The wri- 
ter, Mr. Litton, of Nashville, has just returned from Europe, where 
he spent several years in the arduous prosecution of chemical studies 
in the laboratories of Wohler, Liebig and other great masters. He 
has come home full of zeal in his favorite science, with ample 
knowledge and skill as a practical chemist, and only wants a situa- 
tion to be useful to his country. Y. 

A new Double Salt, the Sulphite of the Protoxide of Platinum and 
the Sulphite of Soda, discovered and investigated by Messrs A. 
Litton and Schnederman. 

This compound is formed, when sulphurous acid gas is conducted 
into a solution in water of the chloride of platinum, and this fluid is 
saturated by the carbonate of potash. By this method is produced a 
very voluminous and almost colourless precipitate, which, as investi- 



A New Double Salt. 



155 



gallon showed, is a double salt of the sulphite of the protoxide of 
platinum u-ith the sulphite of soda. 

This body is, when dried, an amorphous, white powder; when 
moist it has a yellowish tinge, which is the deeper, the more the solu- 
tion is concentrated, from which it is precipitated. In cold water it 
is slightly soluble. The solution is colourless, and neutral, and 
leaves the salt, upon evaporation, as a white varnish-like substance. 
In warm water it is more soluble, since the hot saturated solution 
becomes, upon cooling, troubled and untransparent: however, the 
quantity dissolved is always small. In alcohol it is insoluble. 
From its solution in water it is precipitated, by the chloride of 
sodium and several other salts, as a fleecy powder, and the compound 
thus thrown down is perfectly white. 

A remarkable property of this salt is that, when dissolved in wa- 
ter, the presence of platinum is not indicated by its common tests. 
The solution remains unchanged upon the addition of sulphuretted 
hydrogen and hydrosulphuret of ammonia. When, however, an acid 
is at the same time added, by which the salt may be decomposed, the 
fluid, at the ordinary temperature, is slowly colored; by heating it 
becomes immediately a brownish red, and the sulphuret of platinum 
soon falls down. This precipitate is soluble when heated in solu- 
tions of the sulphurets of the alkalies. By the caustic alkalies the 
salt is not decomposed. 

By acids, even when they are diluted, it is decomposed, and, with 
the development of sulphurous acid, dissolved. The solution in 
hydro-chloric acid, gives, upon evaporation, crystals of the chloride of 
sodium, and, upon the addition of ammonia, a green crystallinish 
precipitate of the platina proto-chloride of the hydro-chlorate of am- 
monia. The solution in sulphuric acid gives, when evaporated, crys- 
tals of the sulphate of soda, and presents the dark color of the sul- 
phate of the protoxide of platinum. By a certain degree of concen- 
tration, metallic platinum falls down from this solution, a property 
which was found to belong to the sulphate of the protoxide of pla- 
tinum prepared for this purpose. The solution in nitric acid assumes 
a deep brownish-red color, from which, by the addition of sal ammo- 
niac, no precipitate is obtained; if, however, the fluid be then 
evaporated almost to dryness, the platino-chlorido of the hydro- 
chlorate of ammonia is found in abundance. The brownish-red 
color seems to arise from the formation of the sulphate of the deu- 



156 



A New Double Salt. 



toxide of platinum, with which the reaction towards sal ammoniac 
agrees. In a solution of the cyanuret of potassium, the double salt 
is very soluble, from which, by evaporating, crystals of the platino- 
cyanuret of potassium may be obtained. 

When the salt is exposed to a temperature of 200° (Centigrade), it 
loses completely the water which it holds chemically united. Heated 
to 240° it suffers no further change, but exposed to a still greater 
heat it undergoes decomposition. This is completely effected by 
continued exposure to a red heat, whereby a quantity of the sulphate, 
and sulphite of soda, with metallic platinum, remains behind. 

In order to determine the quantity of soda and platinum, the salt 
was mixed with sal ammoniac and heated red hot. The residue, 
which consisted of chloride of sodium and metallic platinum, was 
thoroughly washed with distilled water, and the platinum weighed: 
while the water, after the addition of sulphuric acid, was evapo- 
rated to dryness, in order to determine the soda as a sulphate. To 
determine the quantity of sulphurous acid, the salt was diffused 
through water, into which chlorine was conducted, and the sulphuric 
acid thus obtained by oxidizing the sulphurous, was precipitated by 
the chloride of barium. 

Of the salt dried by 200° (Cen.) 

1st Exp. 1.850 grs. gave 1.190 sulphate of soda=0.6214 soda; 
and 0.543 platinum — 0.587 protoxide of platinum. 

2d Exp. 1.108 grs. gave 0.328 platinum=0.3546 protoxide of 
platiiaum. 

3d Exp. 1.488 grs. gave 0.954 sulphate of soda=0.418 soda. 
4th Exp. 0.867 grs. gave 1.234 sulphate of baryta=0.3395 sul- 
phurous acid. 

5th Exp. 0.874 grs. gave 1.249 sulphate of baryta=0.3436 sul- 
phurous acid. 

These numbers give for the composition of the salt, when free 
fromi water, the following formula: 

(3Na.O S0,+ Pl.O SO,) 
According to which in one hundred parts are contained, 

Calculated, Experiments, 

1 2 3 4 5 
Soda, 28.53 28.18 28.09 

Protoxide of platinum, 32.44 31.73 32.00 
Sulphurous acid, 39.03 39.16 39.32 



A New Double Salt. 



157 



The salt, -when dried at 100° (Cen.), lost upon being heated to 200° 
according to three different experiments, 3.90, 4.28, 4.16 per cent, 
of water; from which, for the composition of the salt containing wa- 
ter, is obtained the following formula: 

2 (SNa.O S0,+P1.0 S0,)+3H0. 
according to which formula, the water should amount to 3.94. 

When protoxide of platinum is diffused through water and sulphu- 
rous acid conducted therein, it is gradually, although difficultly, dis- 
solved with a greenish brown color, and from this solution, by the 
carbonate of soda, the above described salt may be obtained. 

If the salt is dissolved in only so much diluted sulphuric or hydro- 
chloric acid as is requisite for its solution, and the fluid then evapo- 
rated by a gentle heat, in proportion as the sulphurous acid escapes, 
a yellow powder falls down, which is also a compound of the sul- 
phite of the protoxide of platinum, with the sulphite of soda, but 
containing a smaller quantity of the latter than the above salt. 

After being well washed and dried by 100° (Cen.) 

1 Exp. 0.884 grs. of this salt gave 0.306 sulphate of soda=0.l341 

soda; and 0.410 platinum=0.4432 protoxide of platinum. 

2 Exp. 0.443 grs. gave 0.487 sulphate of baryta=0.1339 sulphu- 

rous acid. 

These numbers give for the salt this formula — : 
(Na.O S0,+P1.0 SO,)+HO., 
according to which the salt contains in 100 parts: 

Calculated. Experiment. 

1 2 



Soda, 14.81 15.17 

Protoxide of platinum, 50.53 50.13 
Sulphurous acid, 30.40 30.22 

Water, 4.26 

The quantity of water was not directly found. 

This salt is difficult to be obtained in a large quantity, because it is 
tolerably soluble in water, and after being well washed in order to 
free it from all impurities, but comparatively little remains upon the 
filter. When dissolved in water, its solution acts feebly acid; it is 
not precipitated by chloride of sodimn, but its solution exhibits other- 
wise most of the properties of the first described salt. 

Above I have sent you a translation of the researches made by a 



158 



Surgical Diagrams. 



young German chemist and myself in the laboratory of Professor 
Wbhler, at Gottingen. Should the paper not be too different from 
such as find admittance into your journal, will you please publish it. 

Yours truly, 

Nashville Dec. 16, 1842. A. LITTON. 



SURGICAL DIAGRAMS. 

Dr. Gross, the Professor of Surgery in the Louisville Medical 
Institute, has just had completed, at his private expense, a series of 
magnified and colored drawings, which will add greatly to the inter- 
est and practical value of the future prelections from his chair. 
There are one hundred and fifty figures comprised in fourteen colored 
plates, illustrating the diseases of the urinary and genital 
organs; diseases of the recttim; aneurism and diseases of the veins; 
diseases of the eye; dislocations of the hip-joint, and the manner of 
reducing them; hernia; polypus of the Twse; diseases of the mammary 
gland; inflammation, abscess, mortification; malignant pustule; ery- 
sipelas; cancer of the lip; fungus hematodes; clubfoot; hare-lip; 
and syphilitic diseases of the skin. These drawings are made on 
a large scale, so as to be seen from any part of the room, and are 
executed in the highest style of art. Of their value we need not 
speak more particularly; it Avill be readily appreciated by those for 
whose benefit they are intended. On the whole, they render the 
material for instruction in this department quite as ample as that of 
any other in this richly endowed institution. 

These figures were drawn and colored — partly from copies, partly 
from nature — by Mons. A. Suminski, a gentlemanly and accom- 
plished Pole, who has sought refuge in this country from the persecu- 
tions of those who lord it over his native land. His merit as an art- 
ist is of the very first order. He draws with wonderful accuracy and 
rapidity, and his coloring is as perfect as art can make it. If any of 
our brethren, here or elsewhere, wish to be supplied with matters of 
this kind, we can recommend iVIr. S. to them with great confidence. 

C. 



Report of the Chanty Hospital, New Orleans. 



159 



BEPOET OF THE CHIEITT HOSPITAL, XEW OELEASS. 

We are indebted to Dr. Barton for a copy of this report. The 
whole number of patients admitted into the hospital, from January 
1830, to January 18-13, a period of thirteen years, is fifty-nine thou- 
sand two hundred and one. Of these, forty-one thousand eight hun- 
dred and twenty are derived from foreign countries, chiefly from Ire- 
land, Germany, England and France. Of the States, Pennsylvania 
has furnished the largest number, next comes New York, then Vir- 
ginia, then [Massachusetts, &c. Of the forty-one thousand eight 
hundred and twenty patients from abroad, Ireland alone has furnished 
one half! During the year ending January, 1843, there were four 
thousand four hundred and four persons admitted. Of these, three 
thousand five hundred and sixty had resided in the city less than 
three years, eight hundred and forty-one over three years; three thou- 
sand five hundred and sixteen were discharged, and seven hundred 
and four died. The most frequent diseases of that year were inter- 
mittent, yellow and remittent fever; rheumatism; dysentery; ulcer; 
syphilis; mania-a-potu; diarrhoea; contusions, &c.; their frequency 
being in the order named. We regret to learn that the financial 
affairs of the institution are so deranged. Its support is derived from 
private and public donations, and from Legislative grants; some of 
the latter have not been as productive as was anticipated. The 
expenditures have far exceeded the receipts, and the administrators of 
the establishment enter upon a new year with a load of debt amount- 
ing to $50091,32, which at the end of the year will be increased to 
nearly $80,000. To remedy this large and constantly increasing 
deficit, the report proposes that a tax be levied on the passengers 
arriving at the port of New Orleans, viz: on steerage passengers from 
foreign ports, 82,00 per head; on deck and steerage passengers from 
the United States, fifty cents; on cabin passengers from foreign ports, 
$3,00; on those from the United States, 81,00; leaving the inhabit- 
ants of the city, who have so many other calls on their charity, 
entirely exempt. A law similar to this is already in force, but 
owing to a defect in its provisions, or in its administration, the receipts 
have fallen far short of the amount anticipated. The perfect reason, 
ableness of the proposed capitation tax is, we think, sufficiently appar- 
ent, as it will to a great extent make the sources of the vast expen- 
diture of the institution, subservient to its support. The annual in* 



160 



Report of the Charity Hospital, New Orleans. 



come under the new tax will, in the opinion of the Board, afford a 
permanent fund for the corporation; and it is to be hoped that the 
Legislature will comply with the suggestion, and not suffer so noble 
a charity to be destroyed. "Wc cannot close its doors," says the re- 
port; "the sick, destitute and distressed must have relief; we dare not, 
if we were even so disposed, shut the door of charity against them." 
The four thousand five hundred patients annually received into this 
hospital are of those "who cannot expect aid elsewhere." God for- 
bid that such aid should be withheld. C. 



We beg leave to call the attention of our readers to the card of 
Messrs. Erringer & Co., on the 4th page of the cover. They are 
ingenious and faithful workmen, and will, we are sure, be able to 
please the most fastidious. C. 



THE 



WESTERN JOURNAL 

O F 

MEDICINE AND SURGERY. 

/ 



MARCH, 1 843. 



Art. I. — An Experimental and Critical Inquiry into the 
Nature and Treatment of Wounds of the Intestines. By 
Samuel D. Gross, M. D., Professor of Surgery in the Lou- 
isville Medical Institute. 

[No. 3. CONTINDED FROM PAGE 141.] 

S.— Method of JoberL 

Another mode of treating wounds of the intestines, involv- 
ing their entire circumference, was proposed in 1822 by 
Mons. A. J. Jobert, of France, well-known as the au- 
thor of a very valuable and elaborate treatise on the sur- 
gical diseases of tbe alimentary canal. It is founded on a 
series of experiments on dogs, and has recently been em- 
1 



162 



Gross on Wounds of the Intestines. 



ployed in several instances upon the human subject. The ope- 
ration is divided into three stages, and the apparatus required 
for executing it consists of: i. A pair of probe-pointed scis- 
sors; 2. A pair of dissecting forceps; 3. Two double liga- 
tures, carefully waxed, rounded, and from six to eight inches 
long; 4. Four common sewing needles; 5, Several curved 
needles for stitching up the outer wound; 6. Sponges, warm 
water, pledgets of lint, adhesive plaster, square compresses, 
and a broad bandage.* 

The patient, lying on his back near the edge of the bed, is 
placed in the most favorable manner for the thorough relaxa- 
tion of the abdominal muscles. The prolapsed bowel is then 
washed with tepid water, and the edges of the wound, if 
ragged and bruised, are pared with the scissors. The 
next step is to dissect off the mesentery for several lines from 
each end of the injured gut, an operation which is commonly 
attended with some degree of hemorrhage, wliicli has a tendency, 
however, to moderate the subsequent inflammalion. When very 
profuse, it may become necessary to secure the divided ves- 
sels with temporary ligatures, which are lo be removed before 
the parts are replaced into the abdomen. This conylitutes 
the first stage of the operation. 

The second stage consists in the introduction of the nee- 
dles. To accomplish this the surgeon seizes the upper end 
with the left hand, while with the right, in which he holds a 
thread armed at each extremity with a straight and moderate 
sized needle, he traverses the anterior wall of the intestine 
from within outwards, at the distance of three lines from 
the edge of the wound, so as to form a loop with its 
convexity upwards, and which is now to be intrusted to 
an assistant. A second thread is then carried in the same 
manner through the corresponding part of the posterior wall, 
when the operator, either with his fingers or with a pair of 



' Trailfe Theorique et Pratique dcs Maladies Chirurgicalcs du Canal 
Intestinal, par A. J. Jobert; T. i, p. 88. Paris, 1829. 



Gross on Wounds of the Intestines. 163 

dissecting forceps, inverts the coats of the lower end, and so 
places the serous surface within the tube. At this moment 




there is apt to be some contraction of the intus-suscepted 
parts, which may be allayed, if necessary, by applying to 
them a weak solution of opium. 

Having eflected the inversion of the lower end, the surgeon 
introduces into it the index-finger of the left hand, for the 
double purpose of preventing it from unfolding itself, and 
of serving as a guide to the needles. With the thumb and 
fore-finger of the other hand, he now seizes the two needles 
of the anterior thread held at the same level, and carrying 
them along the radial margin of the finger which is in the 



164 Gross on Wounds of the Intestines. 

lower end, he pierces its anterior doubled wall from within 
outwards, the instruments being brought out at the distance 
of a line from each other. The needles attached to the pos- 
terior thread are conveyed along the ulnar border of the fin- 





ger, and made to traverse the bowel at a point opposite to the 
preceding. Then, approximating the injured parts as closely 
as possible, he withdraws the finger, and gently pulling at the 
threads, thus gradually introduces the upper end into the 
lower. The invagination may be facilitated, if necessary, 
with any smooth, round body. Having restored the bowel 
into the abdomen, the ligatures are twisted together and placed 
at the inferior angle of the external wound, which is cov- 
ered with adhesive strips, a compress and a bandage. On the 
fourth or fifth day, when the union is said to be sufficiently 
firm, the threads are withdrawn. 

The object of this method is to bring the two serous surfaces 
of the bowel into contact with each other, and thus promote 
their re-union. Jobert states that he found in his experi- 



Gross on Wounds of the Intestines. 



165 



ments upon dogs, at the expiration of the twelfth day, a 
linear cicatrice indicating the place of adhesion between tlie 
two ends of the gut, unaccompanied, in the majority of cases, 
by any particular dilatation of the upper one. Internally 
there was a sort of artificial valve, the result of the invagi- 
nation, which floated about in the tube, and formed an inclin- 
ed plane which allowed a free passage to the alimentary 
bolus. The mucous membrane appears to have been uninter- 
ruptedly continuous. In the five dogs upon which this ope- 
ration was performed by Jobert, perfect recovery took place. 
There was no serious disturbance in the functions of the ani- 
mals, not even in that of defecation.* 

There are, I believe, only two cases on record in which 
this course of proceding was attempted on the human sub- 
ject. The first is that recently communicated by Mons. 
Julius Cloquet to the Royal Academy of Medicine of Paris.j 
The patient was affected with strangulated hernia, attended 
with mortification of the entire cylinder of the intestine. 
After having cut away the whole of the sphacelated parts, 
Cloquet invaginated the divided extremities, and maintained 
them in apposition by the method of Jobert. As soon as it 
was ascertained that nothing escaped from the tube on pres- 
sure, the bowel was returned, and the abdominal wound 
secured in the usual manner. When the case was reported 
fifteen days had elapsed since the operation, without the occur- 
rence of any untoward s-ymptoms, and with the prospect of a 
speedy cure. 

The other case fell under the observation of Professor 
Berard, who presented an account of it, a few years ago, to 
the Anatomical Society of Paris. He was called to a female 
who, in a paroxysm of mania, cut off two feet of her small 
bowels. He treated the case according to the process of 
Jobert, but death occurred in thirty six hours without 
the slightest adhesion between the contiguous surfaces.J 

'Op. cit. p. 91-'2-'3. 
+ Archives Generales, T. xi, 648, 
} London Medical Lancet for 1835-'6, p. 45. 
1 * 



166 



Gross on Wounds of the Intestines. 



The method of Jobert was modified, soon after being made 
known, by Julius Cloquet, the distinguished anatomist and 
surgeon. Instead of inverting the lower, and introducing the 
upper end, he advises simply to pass the needle through the 
walls of the intestine, a few lines from the division, and to 
draw the lips of the wound against each other, until the serous 
surfaces are brought fully into contact. To maintain them in 
this situation several sutures are required, the ends of which 
are to be cut off near the knots, when the bowel is returned, 
and the operation completed.* 

Finally, Jobert has proposed the following expedient,! 
which, it appears, he has also employed with success in 
his experiments on the inferior animals, though he has not 
tried it on the human subject. Taking care to distinguish the 
extremities of the divided gut from each other, he traverses the 
anterior wall of the upper with a silk thread armed with two 
needles. Both needles are then carried to the inferior end, 
and passed separately through the anterior wall from within 
outwards, when by gentle tractions the operator inserts the 
extremities into each other, to the extent only, however, of 
about one line and a half to two lines, without any previous 
introversion of their edges. The needles are now to be given 
to an assistant, when, taking another, which should be ex- 
ceedingly fine, and armed with a very delicate thread, he 
plaits the serous membrane of the upper end, and afterwards 
that of the lower. The ligatures are to be tied with a double 
knot, in such a manner as to invert the inferior extremity, or 
turn it in upon itself, and thus bring tlie serous surfaces in 
apposition with each other. The ends are left hanging out at 
the external wound. Three sutures made in this way are 
generally sufficient to preserve the relations of the parts. 

Jobert does not consider this method applicable to young 
subjects, on account of the great fragility of the serous mem- 



* Jobort, op. cit. T. i, p. 93. — Tavernier's Operative Surgery, transla- 
ted by tlie aullior, p. 277. 
t Op. cit.^T. i, p. 93. 



Gross on Wounds of the Intestines. 



167 



brane and the facility witli wliich it is torn. Lately, hoM'ever, 
he employed it upon a pup with the most perfect success; the 
animal speedily recovered, and the functions of the digestive 
canal were executed with their accustomed vigor. 

In longitudinal wounds, Jobert employs a procedure very 
similar to that of Lembert, described in the next section, 
that is, he inverts the edges, and keeps them in contact by 
several points of the interrupted suture. The ligatures should 
be placed so near each other as not to permit any protrusion 
of the mucous membrane, or, what is the same thing, they 
should produce, when tied, the most perfect apposition of the 
serous surfaces. The extremities of the sutures may be 
twisted together and brought out at the external orifice, as in 
the method of Le Dran; or, what is preferable, they may be 
cut off close to the knots, or left hanging out separately. In 
the former case, they will fall into the cavity of the bowel: 




in the latter, they may be pulled away at the end of five or 
six days.* 



' Malgaigne, Manuel de Medecine Operatoire, p. 531. Paris, 1837. 



168 Gross on Wounds of the Intestines. 



I subjoin the following experiments in illustration of Mens. 
Jobert's first method. 

Experiment I. — On the 28th of May, assisted by Dr. Cole- 
scott, Dr. Hagan, Mr. Mullen, and Mr. Church, I divided the 
ileum of a small young dog, and inserted the superior into what 
was supposed to be the inferior end. The operation was ex- 
ceedingly difficult and perplexing, nearly half an hour elaps- 
ing before it was completed. With all the skill I could com- 
mand it was impossible to make the ends firmly meet in their 
entire circumference. No vessels required to be tied. The 
gut was carefully returned, and the extremities of the two 
ligatures were brought out at the abdominal wound, which 
was closed in the usual manner. The animal vomited seve- 
ral times soon after the operation, and refused to take food 
on the following day, but not water, which he drank with 
avidity. Late on the third day he died. 

The dissection disclosed the following appearances. About 
two ounces of sero-purulent fluid were contained in the peri- 
toneal sac, which exhibited marks of high inflammation in 
the greater part of its extent. The omentum covered, and 
adhered to, the whole of the intestinal convolutions. The 
small bowels were completely matted together — the lips of 
the wound were in contact but not invaginated — and the con- 
tinuity of the tube was established externally by plastic 
lymph. The ligatures still retained their situation. No fa3- 
cal matter was discoverable in the effused fluid, and it was 
evident that the peritonitis, which destroyed the animal, had 
been induced by the violence inflicted upon the gut in my 
efforts to invaginate the divided extremities. 

Experiment II. — Immediately after the last experiment 
I repeated the method of Jobert upon another dog, 
somewhat larger than the former, and succeeded, after much 
difficulty, in effecting the invagination. The operation oc- 
cupied fully thirty-five minutes; it was exceedingly pain- 
ful, and one of the ligatures lost its hold so much that I was 
obliged to remove and re-introduce it. Several of the mesen- 
teric arteries bled rather freely, but did not require to be se- 



Gross on Wounds of the Intestines. 



169 



cured. The dog suffered considerably for the first three 
days, after which he became more lively, and continued so 
until the fifth of June, when he evinced symptoms of severe 
indisposition, under which he succumbed on the seventh, the 
experiment having been performed on the 28th of May. He 
took food only a few hours before. The ligatures escaped on 
the fifth day. 

The abdominal wound was nearly cicatrized with a small 
plug of omentum interposed between its lips. The perito- 
neum exhibited no unnatural redness or vascularity. The 
small bowel, for about three feet and a half, was enormously 
distended with gas and fa)cal matter, being at least five times 
as large as in health; its coats were thin, soft, and easily torn; 
and the mucous membrane was highly inflamed in patches 
varying in size from a dime to that of a Spanish dollar. The 
wound was situated near the ileo-coecal valve with a mass of 
omentum and the ascending colon intimately adherent to its 
outer surface. On laying open the tube it was found to be 
completely obstructed, the inferior end, which was the inva- 
ginated one, having become firmly united to the inner surface 
of the upper, into which it projected in the form of a mam- 
millated protuberance, six lines in length, tapering at its free 
extremity, and perfectly closed. The part of the small intes- 
tine which intervened between the wound and the ileo-coecal 
valve was slightly diminished in its caliber, as was also the 
entire colon: the latter contained scarcely any fa;cal matter. 
In the stomach was a small quantity of undigested food. All 
the other abdominal viscera were sound. 

Such were the results of the above experiments, which are 
all I have performed with a view of testing this method. 
It may be supposed that they are not sufficiently numerous to 
entitle me to deduce from them any general conclusions. I 
think otherwise. Independently of their unfavorable termina- 
tion, the difficulty which attended their execution would be 
enough to deter me, under any circumstances, from resorting 
to it in the human subject. A practitioner may err through 
ignorance, but when he does so designedly or despite the 



170 



Gross on Wounds of the Intestines. 



most abundant light, neither his own conscience nor the voice 
of the profession will excuse him. If the method of Jobert 
were the only expedient of the sort, we might be justifiable 
in employing it; but, when there are so many others which 
are all decidedly superior, we should be aware how we give 
it our sanction. As it is, I do not hesitate to denounce the 
proposal as unnecessarily harsh in its execution, uncertain in 
its results, and altogether unwarrantable in the present state 
of our knowledge. Of the improvement suggested by Clo- 
quet I iiave no personal knowledge; nor can I say any thing 
more definite of Jobert's other expedient, described in a pre- 
ceding page, and which appears to be merely a modification 
of that of Lembert. 



Gross on Wounds of the Intestines. 



171 



9. — Method of Lembert. 

A very ingenious process of sewing up a wounded intes- 
tine, now to be noticed, was proposed in 1825, by Mons. 
Lembert of Paris, in the second volume of the "Repertoire 
Generale d' Anatomie et de Physiologie Pathologique." 
The number of needles to be employed must correspond 
with the number of sutures designed to be made; they should 
be long, slender, and armed each with a small but strong 
and well-waxed thread. The drawings will fully explain 
the nature of the operation, which is performed in the follow- 
ing manner.* A short stitch, including only the peritoneal 




and muscular coats, is to be taken np on one side of the 
wound, distant about a quarter of an inch from its edge: 

* London Lancet, vol. xi, p. 848. — Johnson's Medico-Chirurgica 1 
Review, vol. xxi, p. 299. — Velpeau, Medecine Operatoire, T.4, p. 137. — 
Vidal, Traite de Pathologie Externe et de Medecine Opera toire, T. 4- p, 
50G. 



172 Gross on Wounds of the Intestines. 

the needle is then carried across the solution of continuity, 
and a similar stitch taken up on the opposite side: in this 
way one suture is to be placed after the other, the interval 
between each two varying from three to four lines, and when 
they are all arranged they are to be drawn firmly together 
and tied with a double knot. By this proceeding, the incis- 
ion is completely closed,* the serous surfaces are intimately 





approximated, and the lips of the wound are inverted or 
turned inwards, forming a kind of valve, about the twelfth 
of an inch long, within the tube. The ends of the threads 
being cut off near the knots, the bowel is returned into the 
abdomen as near as possible to the outer opening, and the 
case treated as under ordinary circumstances. Mons. Lem- 
bert has observed that the sutures usually escape into the 
cavity of the gut by the seventh or eighth day, after having 
cut through the parts which they embraced by ulcerative ac- 
tion, and that the plastic exudation which serves as a bond 
of union between the wounded and the adjacent textures, be- 
comes very quickly organized, and remains a considerable 
period before it is absorbed. 



• The edges of the wound, it will be observed, are only partially uni- 
ted in the drawinfr, as there are only two sutures, which are not ade- 
fjuate to cflbct coini)lete ajjposition and inversion. 



Gross on Wounds of the Intestines. 



173 



Cases are reported in which the proceedinfr here described 
is said to have been successfully employed, not only in the 
inferior animals, but in mortified hernia and wounds of the 
intestines of the human subject. I subjoin the following, 
being all I can find upon record. 

Case I. — Strangulated congenital hernia of the left side — patient forty-one years 
of age — bowel actidentaUy wounded in dividing the stricture — opening an inch 
and a half long — two sutures— recovery in a month. 

This case, related by Jobert, occurred in the hands 
of Professor J. CIoquet,and is the first of the kind on record.* 
Nicholas Lejeune, forty-one years of age, of middle heiglit 
and spare habit, entered the St. Louis hospital of Paris, on 
the 13th of July 1826, with a strangulated congenital hernia 
of the left side, for which he had always been obliged to 
wear a truss. The .tumor, which was of large size, was soft 
and fluctuating, the patient was affected with nausea and 
occasional vomiting, the pulse was small and frequent, the 
thirst urgent, the breathing hurried and interrupted, and the 
abdomen extremely sensitive, with great prostration of 
strength. Every attempt at the taxis having failed, Cloquet 
proceeded to perform the operation. The portion of bowel 
included in the swelling was highly inflamed and enormously 
distended. The stricture was formed by the neck of the sac. 
This was divided with the bistoury, when he tried to effect 
reduction but failed. The instrument was therefore intro- 
duced a second time, to enlarge the incision, and as he was 



* This case is published by Jobert, (op. cit. T. i, p. 280,) as 
having been treated according to his own method, a circumstance which 
may be explained by the fact that he claims to be the discoverer of the 
process above mentioned, and now usually attributed to Lembert. 
Indeed, the question of priority does not seem to be fully decided; but 
as this does not impair the merits of the operation, we shall not stop to 
settle it one way or the other. Mr. Lawrence, (^Treatise on Ruptures, 
p. 30G,) who quotes the case from Jobert, says it was treated according 
to Lembert's method; and Velpeau, (Medecine Operatoire, T. iv, p. 143,) 
evidently considers it as an example of that kind. 

2 



174 Gross on Wounds of the Intestines, 



withdrawing it a portion of the intestine, held by one of the 
assistants, was accidentally opened to the extent of an inch 
and a half, followed by an escape of gaseous and feecal mat- 
ter. With a common needle he immediately sewed up the 
wound, entering it four lines from the cut edge, and bringing 
it out at about one line: having carried it in the same man- 
ner through the other side, he easily inverted the margins of 
the aperture, and thus approximated the serous surfaces. 
Having placed two sutures, he fastened them with a double 
knot, and, satisfied that nothing escaped, cut off the ends 
close to the bowel, which he now pushed into the abdominal 
cavity. Simple dressings were applied to the outer wound, and 
secured by a T bandage. All the unfavorable symptoms rap- 
idly disappeared, and the man left the hospital cured on the 
12th of August. 

Case II. — Patient fifty years of age — strangulated crural hernia of the right side 
— excision of three inches of mortified bowel — number of sutures not stated — 
death in five or six weeks from the use of indigestible food. 

The second case in which this method of enteroraphy was 
attended with a favorable result, occurred a few years ago in 
the practice of Professor Dieffenbach, of Berlin.* The patient, 
a strong, tali husbandman, fifty years of age, had suffered for 
fifteen days from strangulated crural hernia of the right side. 
Various attempts had been made at reduction, but without 
success, by other surgeons, and the probability was that 
the constricted parts had sloughed, and given rise to 



* This case was originally published in the "Wochenschrift filr die 
gasavimte Heilkunde," Nov. 26, 1836. The British and Foreign Medi- 
cal Review (vol. iii, p. 517,) in noticing the case, states that the stran- 
gulation existed only fourteen days, and that it was inguinal, not 
crural hernia. Mr. Lawrence (Treatise on Ruptures, p. 362,) however, 
who obtained his information from the '^Archives generales de Medecine" 
tor March 1837, makes out the case to have been one of crural hernia, and 
so does the writer in the London Lancet for June of the same year, and 
who translated his article from Grsefe and Walther's Journal, vol. xxiv, 
No. 3. 



Gross on Wounds of the Intestines. 



175 



an effusion of frecal matter. This, indeed, was found, on lay- 
ing open the swelling, to be the case. The fold of intestine 
contained in the sac presented, near its upper part, an aper- 
ture large enough to admit the thumb. As the faeces did not 
readily escape, even after the division of the stricture, owing 
partly to the narrowness of the hernial opening, and partly 
to the constriction of the gut, the operator destroyed the 
preternatural adhesions and drew the canal for some distance 
out of the abdomen. He then excised the whole of the mor- 
tified portion, which was at least three inches in length. The 
corresponding part of the mesentery was removed with a pair 
of scissors, and a small artery, which was divided in this step 
of the proceeding, was secured with a ligature, the extremi- 
ties of which were cut oil' close to the knot. The open ends 
of the bowel, which were held by assistants, contracted to 
such an extent that they would not admit any thing larger 
than a writing-quill, and the mucous coat was everted. Hav- 
ing united the angular wound of the mesentery with a very 
fine thread, the lips of the intestinal breach were treat- 
ed according to the process of Lembert, when the parts 
were genily replaced within the abdomen. Shortly after- 
wards castor-oil was administered in large quantities, 
which was subsequently repeated with croton-oi], and the 
patient was ordered to remain for sometime on his feet; 
copious evacuations ensued, with great improvement in all 
the symptoms. For a few days the treatment was mildly 
antiphlogistic, and the only remedy given was some castor-oil 
in laurel-water. The stools soon became natural, the exter- 
nal wound discharged healthy pus, and in a month the patient 
was so well that he was able to resume his occupation. 

The man continued in excellent health for several weeks, 
when, after severe labor in the field, and the use of very indi- 
gestible food, he was suddenly seized with violent pain in the 
abdomen, vomiting and constipation, under which he died. 
Two diseased conditions were found within the abdomen. In 
the left lumbar region a portion of small bowel had coiled 
around another portion, which it had thus strangulated: above 



Gross on Wounds of the Intestines. 



this point the ileum and jejunum were much inflamed, adher- 
ent, covered with flakes of lymph, and distended with excre- 
mentitious fluid, which was also found in the duodenum and 
stomach. The gut below the seat of the strangulation was 
empty and contracted, descending in this state in front of the 
lumbar vertebra3 on the right side, where several convolutions 
were closely adherent to the walls of the abdomen and to 
eacl) other. In detaching them, a few drops of pus escaped, 
and a knot of silk was met with, indicating the exact spot at 
which the ligature had been inserted, and consequently the 
place where the tube had been divided. On cutting it open, 
the parts were found to be united through the medium of a 
smooth, even cicatrice, half a line broad, and interrupted 
merely at two points by so many threads, which were still 
adherent to the surface. There was no perceptible contrac- 
tion of the caliber of the tube. 

Case III.— Accidental wound of the intestine in operating on crnral hernia- 
patient fifty-four years old— two sutures with the ends twisted together and 
brought out at tlie external opening — complete recovery. 

A third successful example of Lembert's process has been 
recently published by Mons. Fleury, in a valuable memoir on 
intestinal sutures in the "Archives Generales de Medecine" 
for March 1837. In operating on a crural hernia, in a lady 
fifty-four years of age, a wound was accidentally inflicted on 
the intestine, which was obscured by adhesions. When the 
latter had been destroyed, a portion of gut was drawn out of 
the abdomen, exhibiting a deep mark from the pressure of the 
crural ring. Mons. Jobert, the operator, determined to close 
the cut in the intestine by sutures applied in the manner 
already described, which he accordingly did.* The threads 
being then united, gentle torsion was made which brought 
the external edges of the wound together, and placed the 
serous surfaces in apposition. The bowel was then returned, 
the ends of the ligatures were left hanging through the outer 
opening, where they were secured by adhesive plaster, and 



' See page 167. 



Gross on Wounds of the Intestines. 



177 



ordinary dressing was applied. The symptoms immediately 
assumed a more favorable aspect, the bowels acted well on 
the fourth day, one of the ligatures was withdrawn on the 
sixth, and the other on the eigth day, and in a month the 
wound in the abdomen was perfectly cicatrized. At the end 
of the third month the patient was in excellent health, the 
functions of the alimentary canal being performed without 
any irregularity or impediment.* 

Case IV. — Gunshot wound of the arcli of the colon — tlireo sutures — the ends of 
tlie hgatures cut otf close to tlie knots — complete recovery. 

A soldier, whose case is mentioned by Mons. Baudens,t 
was wounded by a ball, which entered three inches to the left 
of the umbilicus, and passed out at the back not far from the 
spine. A finger conveyed into the wound readily discovered 
a large opening in the arch of the colon, which was accor- 
dingly drawn out of the abdomen; the edges of the fissure 
were inverted, and maintained by three points of suture, in- 
troduced in accordance with Lembert's method, the ligatures 
being cut off close to the knots. The man was bled several 
times at the arm soon after the accident, and subsequently 
the abdomen was covered with leeches. Under this treat- 
ment he rapidly recovered. 

Finally, Velpeau alludes^ to a fifth case in which this 
operation was attended with favorable results' in the human 
subject. It fell under the observation of Liogard, a French 
surgeon, but I am not in possession of the particulars. 

In the following cases, in which the method of Lembert 
was employed, death was produced, in two, by causes appar- 
ently unconnected with the operation, and in the third by 
peritoneal inflammation. The two first, which both occur- 



* British and Foreign Medical Review, vol. iv, p. 512. — Lawrence on 
Ruptures, p. 807. 
t Clinique des Plaies D'Armes et Feu, p. 336. Paris, 1836. 
X Medecine Operatoire, T. iv, p. 143. 

2 * 



178 Gross on Wounds of the Intesstine. 



red in the practice of Mons. Jobert, I shall relate as detailed 
by Mr. Lawrence in his Treatise on Ruptures. 

Case I. — Two incised wounds, one transverse, the other longitudinal, the first 
being united by four, the second by eight points of suture — the ends of 
the ligatures brought out at the external opening — the patient twenty-three 
years of age — death in thirty-eight hours from fwcal effusion. 

A man, twenty-three years of age, was stabbed in the 
abdomen with a knife, cutting a portion of intestine, which 
protruded at the wound, in two places. One of the apertures 
was transverse, and ten or twelve lines in length; the tunics 
being completely divided only to the extent of about two- 
thirds of an inch. It was united by four points of suture, 
with a common needle and a single tliread, carried through 
the parts in the manner above mentioned. The extremities 
of the ligatures were then twisted together, which had 
the effect of approximating the margins of the incision by 
their external surfaces, and consequently of bringing the 
opposed serous membranes into contact with each other. These 
threads were next held by an assistant, while the longitudinal 
wound, ten or twelve lines in length, was united in a similar 
manner by eight points of suture. The intestine was then 
replaced in the abdominal cavity, the ends of the threads 
being retained on the outside. The patient died in thirty, 
eight hours in consequence of effusion into the peritoneal 
cavity from other penetrating wounds of the intestinal tube. 
The sutures in the w^ounds of the bowel were covered by a 
layer of lymph, without any appearance of pus. No thread 
was visible on the interior; nor was there any interval be- 
tween the edges of the solutions of continuity. The longitu- 
dinal wound formed a projection of two lines in height. The 
lips of the division still remained in contact even after the 
removal of the threads; on dragging them apart it was found 
that they had been united by plastic lymph. 



Gross on Wounds of the Intestines. 



179 



Case II. — Irreducible scrotal hernia — rupture of the bowel by a blow — opening 
closed by two points of suture — death in less than twenty-four hours. 

In this case, the patient, who had been affected with a large 
irreducible scrotal hernia, received a violent blow on the 
swelling, followed by symptoms indicating injury of the intes- 
tinal canal. On opening the tumor a wound of the bowel 
was discovered, which was united in the same manner as in 
the former case, by two points of suture. Death ensued in 
the night after the operation. The edges of the intestinal 
wound were found united by plastic lymph, as in the preced- 
ing instance. 

Case III. — Two gunshot wounds eight inches from each other — excision of the 
whole of the injured part — ligation of the mesentery — number of sutures not 
mentioned — death on the third day from fsecal effusion caused by an opening 
in the coecum. 

Finally, a third unsuccessful case is recorded by Mons. M. 
L. Baudens, in the work already quoted.* A soldier of the 
thirteenth regiment of the line was struck by a ball which 
entered a little to the right of the umbilical region, and passed 
out behind in the corresponding loin. On introducing the 
fore-finger into the anterior opening, which was a little larger 
than usual, the surgeon came in contact with two flattened 
balls, which had been forced from the man's watch-fob into 
the abdomen at the moment of the accident. Having ex- 
tracted these foreign bodies, he conveyed the finger down to 
the surface of the bowel, which, from its hard and contracted 
state, he at once supposed to be injured. The affected por- 
tion of the tube was then withdrawn, and the simple slit-like 
aperture which it presented closed with three points of suture. 
He was about to return the protruded bowel, when, by some 
exertion of the patient, a fresh portion descended, which was 
found to have been completely perforated by the ball, eight 



* Clinique des Plaies D'Armes et Feu, p. 333. 



180 



Gross on Wounds of the Intestines. 



inches from the seat of the other injury. Believing that the 
best plan would be to remove the whole of the affected part, 
he accordingly excised it, having previously included the 
mesentery in a ligature, to prevent hemorrhage. The edges 
of the new wound were then brought into contact, and re- 
tained by Lembert's process; the intestine was reduced, and 
the ligature just alluded to left hanging out at the external 
opening. Death occurred on the third day. The sutures 
were covered with a considerable quantity of plastic lymph, 
which was already organized; strong adhesions existed be- 
tween the injured parts and the rest of the small bowel; the 
perforated omentum had formed extensive attachments; and 
some coagulated blood was detected between the intestinal con- 
volutions. In prosecuting the dissection, Mons. Baudens dis- 
covered an opening in the ccccum with an eflusion of ibces, 
which had been already bounded by the adhesive process; 
the peritoneum, at this part, was red and very much inflamed, 
and this at once accounted for the fatal termination of the 
case. 

The late Baron Dupuytren pioposed, a few years ago, a 
modification of Mons. Lembert's method, consisting mainly 
in the use of the continued instead of the interrupted suture, 
as recommended by the latter surgeon. The principal advan- 
tages attributed to it are, that it is more simple, and that it insures 
more accurate apposition of the edges of the wound, thereby 
lessoning somewhat the risk of stercoraceous effusion.* 

To execute this suture the surgeon takes hold of one end 
of the bowel with the left thumb and fore-finger, the latter 
being within the tube, and carries a needle through its tunics 
a line and a half from the wound, and as near as possible to 
the mesentery. Leaving a length of thread of about five 
inches, he intrusts this to an assistant, while he himself 
grasps the other end, which he treats precisely in the same 
manner. Having made these two preliminary points, the nee- 



" TraitfJ Theoririue et Pratique dcs Blessures Par Armcs do (iuerre, 
ridige par Paillard et Marx, T. i, 186. Paris, 18:34. 



Gross 071 Wounds of the Intestines. 



ISl 



die is conveyed alternately from one side of the breach to the 
other, as in the glover's suture, until the entire track is sew- 
ed up. The thread being cut off at the same distance from 
the bowel as at the other angle of the wound, the different 
stitches are adjusted with a pair of forceps and rendered 
equally tense throughout. The parts are now returned into 
the abdomen, and the ends of the ligature brought out at the 
external incision, where they are to be left for five or six 
days until the adhesive process is sufficiently advanced, when 
they may be gently pulled to encourage their separation. If 
this should be attended with much difficulty, the protruding 
extremities may be cut off on a level with the skin, and the 
remainder left to make its way into the interior of the canal. 
Or, the ends may be cut off in the first instance, and a thread 
tied to the central loop of the suture before the bowel is re- 
stored to the abdomen. By pulling this, when the proper 
period has arrived, the suture may be easily withdrawn. 

The method of Lembert may be further illustrated by the 
following experiments. They amount altogether to twenty- 
three in number, and were performed with great care. It 
will be seen that all, excepting four, had a favorable termina- 
tion, notwithstanding that the wounds in some of them were 
of unusual extent. In three, death was produced by peritoneal 
inflammation, from the escape of fsecal matter; in the other, the 
animal perished without any obvious or assignable cause. In 
three of the cases the wound was transverse, in the other lon- 
gitudinal. In the latter — Experiment II — it was three inches 
and a half in length, and closed by eleven sutures; death occured 
on the thirteenth day from the extravasation of fascal matter, 
occasioned by the imperfect union of the edges of the incis- 
ion at its upper angle. All the sutures, except two, had dis- 
appeared, the wound was scarcely more than two inches long, 
and the reparation had been effected mainly through the 
intervention of an adjacent fold of the small intestine. The 
caliber of the tube was of the natural size in nearly all the 
cases in which the parts were examined after death. In a 
considerable number of them the consolidation of the lips 



182 



Gross on Wounds of the Intestines. 



of the wound was remarkably perfect, even at a very early 
period after tlie experiment, much more so, indeed, than after 
the use of llie continued or interrupted suture. 

a. — Transvei'se Wounds. 

Experiment I.— Complete section of the ileum— four sutures— death in thirty- 
seven hours from peritoneal inflammation. 

June 17, 1842, in the presence of Dr. McDowell, Profes- 
sor Miller, Dr. Hagan, and Dr. Colescott, I opened the abdo- 
men of a middle-sized and full-grown dog, and exposed a fold 
uf the small bowel, two feet from the ileo-ccBcal valve, which 
was divided entirely across, and the wound closed with four 
interrupted sutures, equidistant from each other. The ani- 
mal bore the operation well, but he soon sickened, and died 
in thirty-seven hours from the time he was removed from the 
table. The outer wound was feebly united by lymph, and 
free from omentum. The abdominal cavity contained six 
ounces of reddish serosity, and the peritoneum, both visceral 
and parietal, was extensively inflamed. The bowels adhered 
to the omentum and to each other at various points, and in 
several of the interstices between them was a small quantity 
of mucous and fa^culent matter. The sutures retained their 
original situation, and their surface was only partially coated 
with lymph. On each side of the mesentery the edges of the 
wound were everted, with a corresponding opening, scarcely 
two lines in length, through which the alvine fluid had 
escaped. 

Experiment II. — Complete division of the small intestine — six sutures — the ani- 
mal lulled at the end of the ninth day. 

Assisted by the gentlemen who witnessed the preceding 
experiment, I made a transverse section of the small bowel, 
and retained the divided edges by means of six interrupted 
sutures, placed ut equal distances from each other. The ani- 
mal, an old slut, bore the operation without much resistance, 



Gross on Wounds of the Intestines. 



183 



and suffered apparently very little afterwards. At the end of 
the ninth day, the cure being considered as established, she 
was killed. The external wound, which presented nothing 
unusual, contained a process of omentum: there was no adhe- 
sion of the injured part to the adjacent folds of the gut or to 
the wall of the abdomen, but it was united very firmly to the 
epiploon, which thus served to point out its situation. The 
peritoneum was free from inflammation, and the same was 
the case with the mucous membrane, even in the immediate 
vicinity of the lesion. 

Experiment III. — Complete section of the small bowel — six sutures — faecal 
effusion — deatli from peritoneal inflammation. 

The subject of this experiment was a young dog of middle 
size, in which the bowel, cut entirely across, was sewed up 
with six sutures, as nearly as possible equidistant from each 
other. The operation, which was borne well, was performed 
on the 14th of July, and death occurred on the seventeenth, 
or about three days and a half after; the animal having all 
along refused food, and also, during the last forty hours, drink. 
On examination I discovered about five ounces of thin, dirty 
colored fluid, evidently of a fteculent nature, with high marks 
of peritoneal inflammation. Very little adhesion existed be- 
tween the bowels, except at the seat of the wound, the 
edges of which were widely separated from each other, all 
the sutures, save one, having lost their connexion. Small 
gangrenous patches were seen in different parts of the ileum, 
and the mucous membrane was deeply inflamed at several 
points. The external wound was firmly united. 

Experiment IV. — Entire division of the small intestine — sis sutures — ftecal effu- 
sion — death from peritoneal inflammation. 

From a small but stout and full-grown dog, I removed a 
knuckle of the ileum, which was cut completely across, about 
two feet from the ileo-ccecal valve. The edges were brought 



184 



Gross on Wounds of the Intestines. 



together, and maintained in apposition by six sutures, equi- 
distant from each other. The dog struggled a good deal during 
the operation, from the effects of which, however, he speedily 
recovered, taking food and drink as usual. At the end of the 
seventeenth day, being in good plight, and the cure fully 
established, he was killed. The following appearances were 
observed on dissection. 

The abdominal wound was completely healed, a process of 
omentum being, as usual, prolonged into it. The injured 
bowel adhered to a neighboring fold for about three mches, 
through the medium of a smooth and polished texture re- 
sembling serous membrane. A small process of the epiploon 
was united to the outer surface of the wound, and exhibited 
a dark modena appearance, from the effusion, probably, of 
blood at the time of the operation. The omentum was spread 
over the whole surface of the bowels, which were entirely 
free from adhesions, except at the place before alluded to. 
Their movements must therefore have been altogether un- 
impeded. Internally, the reparation was perfect. The su- 
tures had all disappeared, and the villous edges were not only 
in apposition with each other, but continuous throughout 
their entire extent. In fact, the cicatrization could not have 
been more beautiful or complete. The caliber of the tube at 
the seat of the lesion was of the natural size. 

Experiment V. — Complete division of the upper part of the small bowel — six 
sutures — the animal killed at the end of the sixteenth day. 

The dog employed in this experiment was small but 
full-grown, and had fasted twenty-four hours. The bowel 
was divided within fifteen inches of the pyloric extremity of 
the stomach, and the wound closed by six sutures. No un- 
toward symptoms followed the operation, which was borne 
without any unusual resistance. He was killed at the end of 
the sixteenth day, being apparently well but somewhat ema- 
ciated. The intestines were every where free from morbid 
attachments. The omentum adhered around the inner wound, 



Gross on Wounds of the Intestines. 



185 



and projected into the outer, precisely as in the preceding 
experiment. Half of the villous portion of the breach was 
completely repaired, tlie remainder only imperfectly, three of 
the sutures being still retained, and the lips, altliough in con- 
tact, not firmly united with each other. The mucous 
membrane was of a pale rose color, but not inflamed, and the 
caliber of the tube natural. 

Experiment VI.— Transverse vvoimd six lines in extent— tliree sutures— the ani- 
mal killed at tlie end of a fortnight. 

A transverse incision, six lines in length, was made into the 
lower portion of the ileum, and closed by three points of 
suture. The dog, a small young tarrier, was scarcely alFected 
by the operation, took food as usual, and was quite playful. 
At the end of a fortnight he was killed. 

A plug of omentum was prolonged into the outer wound, 
which was nearly cicatrized. The injured bowel adhered to 
the mesentery and to a neighboring knuckle, by a small quan- 
tity of firm, organized lymph, partially transformed into 
serous texture. Internally, the wound was beautifully re- 
paired, the villous edges being every where in contact, and in 
the greater part of their extent inseparably connected with 
each other. One suture, however, still remained, with well- 
marked traces of the other two. The tube was fully as capa- 
cious at the seat of the injury as elsewhere. 

Experiment VII. — Transverse soctiou of the small bowel — four sutures — re- 
covery. 

In this experiment the small intestine was divided entirely 
across, and the wound dosed by four sutures, which had the 
effect of completely inverting the serous surfaces, as the tube 
was unusually narrow. The animal, a small slut, soon recov- 
ered from the shock of the operation, and escaped from her 
box on the seventh day, in good health. She was seen in the 
street more than a fortnight after; at a period, consequently, 
when it may be supposed she had entirely recovered. 



- 186 



Gross on Wounds of the Intestines. 



Experiment VIII. — Complete division of the smaU bowel — four sutures — death 
in forty-four hours without any assignable cause. 

Having drawn out a fold of the ileum and cut it completely 
across, I approximated the edges of the wound with the same 
number of sutures as in the preceding experiment. These 
had the effect of closing the breach in its entire extent, and 
of bringing the serous surfaces beautifully together. The dog 
seemed pretty comfortable for the first six or eight hours, 
when he began to evince signs of severe sufiering, in which 
he died forty-four hours after he was removed from the table. 
No attempt at re-union was visible in the outer wound. The 
edges of the inner wound remained inverted, except at one 
of its mesenteric angles, where they were slightly separated; 
scarcely any lymph was discoverable upon them, and the 
sutures were as distinct and as perfectly in their places as at 
the moment of their introduction. The ptritoneum in the 
vicinity of the injury was slightly inflamed, but there was no 
adhesion of the intestines to each other or to the walls of the 
abdomen. On laying open the tube, the inverted edges were 
found to form a small valve-like prominence, which was not 
sufficient, however, to produce any obstruction. What was 
the cause of death remains therefore a mystery. The proba- 
bility is that the animal died from the shock of the operation. 

Experiment IX. — Complete section of the ileum — six sutures — the animal killed 
at the end of the twenty-second day. 

The subject of this experiment was a large healthy dog 
that had fasted for twenty-four hours. The small bowel was 
cut completely across within a foot of the ileo-coecal valve, 
and the divided parts were approximated by means of six 
sutures, equidistant from each other. The dog made some re- 
sistance during the operation, and appeared to be considera- 
bly exhausted by it. Nevertheless, he rapidly recovered, and 
was permitted to live till the end of the twenty-second day, 
yvhcn he was killed. 



Gross on Wounds of the Intestines. 



187 



The outer wound was completely healed, and projecting 
into it was a slender process of omentum. There was no 
adhesion between the bowels, or between these and the sur- 
rounding parts, except at the wound, the surface of which 
was covered by a mass of epiploon. The tube, which was of 
the natural size, presented two small sacs or pouches, one 
above and the other below the seat of the breach, which was 
perfectly cicati ized, the villous margins being every where 
continuous with each other. The mucous membrane had a 
healthy appearance; and the animal, notwithstanding his long 
confinement and irregular feeding, was in good order. 

Experiment X. — Two transverse wounds each half an inch in length — one clos- 
ed witii two, the other with three sutures — the animal killed at the end of the 
twenty-second day. 

From a small dog that had fasted nearly a day, I removed 
a loop of the small intestine, and made two transverse incis- 
ions into it, each six line? long, the first four, the other seven 
inches from the ccccum. One of these I closed with two, the 
other with three sutures. The animal bore the operation 
without flinching, and lived, without any untoward occur- 
rence, until the end of the twenty-second day, when he was 
killed. The abdominal wound exhibited the usual appearan- 
ces, that is, it was perfectly cicatrized through the interven- 
tion of a plug of omentum. The bowels were free from 
adhesions, exce()t at the seats of the injury, to each of which 
was attached a small process of the epiploon. One suture 
remained in each wound, but it was evident that their pre- 
sence had not been productive of any mischief, as the contin- 
uity of the villous edges had been perfectly re-established. 
Indeed, the union could not have been more satisfactory. The 
diameter of the tube was natural. 



188 Gross on Wuunds of the Intestines. 



b. — Longitudinal Wounds. 

Experiment I. — Longitudinal wound two inches in length — seven interrnpted 
sutures — the animal killed on the twenly-lourtli day. 

This experiment, together with some of the succeeding ones, 
was witnessed by Professor Miller and Dr. McDowell. It 
consisted in making a longitudinal incision, two inches in 
length, along the convex surface of the small bowel of a mid- 
dle-sized slut, and in bringing the edges together with seven 
sutures at equal distances from each other. The animal suf- 
fered a good deal for the first twenty-four hours, after which 
she became comfortable, and so continued until the twenty- 
fourth day, when, being in good condition, she was killed. 
The external wound was perfectly cicatrized, and contained 
no epiploon. The small bowels were matted together, as 
well as to tlie omentum, by dense, organized lymph, but they 
did not adhere to the wall of the abdomen, nor was there any 
unnatural redness of the peritoneal surface, except at the seat 
of the injury, where a small ecchymotic spot was visible. On 
laying open the wounded intestine, the breach was found to 
be perfectly and beautifully cicatrized in its entire extent, 
save a small point at each extremity, where the union was 
not so complete. At one of these places was a small abscess 
containing a few drops of pus and two ligatures, one parti- 
ally, the other wholly detached. The injured part adhered 
firmly to a neighboring fold of the gut, and was in no wise 
contracted or diminished in its caliber. The adhesion of the 
villous edges of the wound was more perfect, excepting at the 
extremities just mentioned, than I ever saw it before in so 
short a time. 



Gross 071 Wounds of the Intestines. 



189 



Epperiment II. — Longinidiual wound three inches and a half long — eleven 
sutures — death on the thirteenth day from faecal effusion. 

This experiment was performed immediately after the last,' 
and with the assistance of the same gentlemen. The wound, 
extending for three inches and a half along the convex sur- 
face of the small bowel, was closed by eleven sutures, as 
nearly as possible equidistant from each other. The animal 
was exceedingly fractious, and was much exhausted by the 
operation, in other respects already sufficiently tedious. For 
the first few days he was drowsy and listless, refusing such 
food as was offered him. Before the expiration, however, of 
the middle of the first week he became more gay, and in a 
short time appeared to be quite well. He remained thus 
until the twelfth day, when he was taken sick, and on the 
thirteenth he expired. 

The small bowels were extensively united to each other 
and to the omentum, a process of which projected into the 
outer wound. The inner wound had contracted to two inches, 
and all the sutures, except two, had disappeared. The edges 
were nearly four lines apart at their centse, elevated, and 
rounded off, the bottom of the breach, formed by an adjacent 
fold of the intestine, being covered by a layer of tough, organ- 
ized lymph. This had given way at the upper extremity of 
the wound, producing a circular aperture, nearly as large as 
a five cent piece, through which upwards of eight ounces of 
thin, fluid, alvine matter had escaped into the peritoneal cavity, 
where it induced fatal inflammation. The lyinph which con- 
nected the convolutions of the bowel was firm, dense, and 
partially transformed into serous texture. The dog was in 
good condition, and considered out of danger until the occur- 
rence of the accident which carried him off. 

F.iPERiMEST III. — Longitudinal wound one inch and a half long — four sutures 

recovery. 



From a full-grown tarrier a fold of the small bowel was 
3 * 



190 



Gross on Wounds of the Intestines. 



drawn, and an incision, an incli and a half long, made uporj 
its convex surface, directly opposite the mesentery. The 
edges of the wound were brought together by four sutures, 
which had the effect of preventing any protrusion of the vil- 
lous membrane. The dog suffered apparently no inconveni- 
ence from the operation, taking food and drink as before. A 
month after, the cure being considered as fully established, he 
was set at liberty. 

Experiment IV. — Longitudinal wound half an inch long — two sutures — the ani- 
mal killed on the seventeenth day. 

A small pup, not more tiian about four months old, formed 
the subject of this experiment. The wound, only six lines 
long, was made along the convex surface of the intestine, as 
in the preceding experiment, and closed by two sutures. The 
animal was a good deal indisposed for the first forty-eight 
hours, but he gradually recovered his health and appetite, and 
lived until the seventeenth day, when I had him killed. The 
external opening was perfectly healed with the interven- 
tion of a narrow strip of omentum. The small intestines 
were slightly adherent to each other, and the internal wound 
was beautifully cicatrized. Both sutures had disappeared, 
and the villous portion of the breach was perfectly repaired. 
No contraction of the injured part was discoverable. 

Experiment V. — Longitudinal wound three-quarters of an inch in length — three 
sutures — the animal killed at tlie end of the tenth day. 

The subject of this experiment was a small dog, probably 
two or three years of age, into the ileum of which, about its 
middle, I made a longitudinal wound three-lourths of an inch 
in extent, and brought the edges together by three sutures at 
equal intervals. The animal bore the operation well, and 
soon recovered his wonted energy and spirits. He was killed 
at the end of the tenth day, the cure being considered as 
established. 



Gross on Wounds of the Intestines. 



191 



The abdominal wound was nearly healed, with a process of 
epiploon interposed between its inner lips. A small fold of this 
apron-like membrane was also united to the outer surface of 
the intestinal wound, and the affected bowel had contracted 
pretty extensive adhesions to several of the adjacent convo- 
lutions. On laying open the tube the villous edges were 
found to be in close contact with each other, with only a par- 
tial re-establishment, however, of their continuity. The 
sutures still retained their hold, and were buried, as it were, 
in the substance of the mucous membrane. The latter was 
perfectly healthy both above and below the seat of the lesion, 
and the canal itself was in no respect diminished. 

Experiment VI. — Longitudinal wound two inches and a half in length— eight 
sutures — the animal killed at the end of the seventeenth day. 

From a very large and healthy dog, shortly after he 
had eaten a hearty meal, I removed a fold of the upper 
portion of the jejunum, and made a longitudinal incision, 
two inches in extent, along its convex surface, directly 
opposite the mesentery. The edges of the wound were 
approximated with eight sutures, equidistant from each other. 
The animal was exceedingly restive during the operation, 
which was in consequence somewhat protracted, and he lost 
several ounces of blood. For the first few hours he appeared 
languid and exhausted, but he rapidly recovered, and was 
killed at the end of the seventeenth day, being at the time in 
good condition. The outer wound was perfectly healed with 
a plug of epiploon between its inner edges. 'Phe bowels 
were free from adhesions, except at the seat of the injury, 
the surface of which was covered by a small slip of omen- 
tum. The caliber of the tube was of the normal size, and 
the reparation complete. The villous margins of the wound 
were, however, a good deal more elevated than common: 
but it was evident that they were every where continuous 
with each other. The marks of the sutures were still visible. 
The wound had diminished in length about half an inch. 



Gross on Wounds of thi'. Intestines. 



The mucous coat was perfectly sound, and unpuckered. The 
arrangement of the parts is tolerably well seen in the draw- 




ing. 'J"licid;irk line in the centre lepreaents the ridge formed 
by the junction of the lips of the wound, which, as has just 
been stated, were firtnly united through their entire extent. 

Experiment VII. — Longitudinal wound of ilie ilfnim throe hu.hcs in length — 
twelve sDtures — recovery — the iininial killed at tJic end of the twentieth day. 

The subject of this experiment was an old dog, of mode- 
rate size, which had fasted for twenty-four hours. The wound 
was three inches in length, and occupied the lower surface of 
the small gut, two feet from the ileo-ccecal valve. The sides 
of the solution of continuity were approximated by means of 
twelve suttires, placed equidistant from each other. The ope- 
ration was tedious, and the dog was considerably exhausted 
before he was removed from the table. During the afternoon 
he was indisposed to move about, but the next morning the 
re-action seemed to be completely established, and from this 
time he rapidly convalesced. He was permitted to live until 
the expiration of the twentieth day. 

On dissection the following appearances were observed. 
The abdominal wound was entirely cicatrized, and a thick 



Gross 071 Wounds of the Intestines. 193 



plug of the epiploon intervened between its inner margins. 
The injured bowel was firmly united to a process of the mes- 
entery, to the omentum, and to the neighboring knuckles, by 
smooth and organized bands of lymph, strongly resembling 
the serous tissue. The peritoneal lips of the wound were 
scarcely discoverable; aiW as to the villous, they were 
not only in close contact but inseparably blended together. 
In fact, the restoration could not have been more perfect. 
The cicatrice, raised in the form of a narrow ridge, was not 
more than two inches and a quarter in length, the mucous 
membrane was no where puckered or diseased, and the tube 
retained its natural volume. All the sutures had disappeared, 
though the marks of some of them were still visible, and the 
villous edges were somewhat elevated, owing to interstitial 
deposits of plastic lymph. The animal was in good condi- 
tion, having suflered little or no emaciation from his con- 
finement. 

Experiment VIII. — Two wounds, one longitudinal and the other transverse, 
the first one inch long, tlie second three-quarters of an inch — each opening 
closed with three sutures — recoverj- — the animal killed at the end of twenty- 
eight days. 

Into the ileum of a small and very old dog I made two in- 
cisions, about eighteen inches from the ileo-ccecal valve. One 
of the wounds was longitudinal, twelve lines in extent, and 
situated upon the convex surface of the gut, five inches from 
the other, which was horizontal, and three lines shorter. Each 
opening was closed by means of three sutures, equidistant 
from each other. The dog had fasted for twelve or fifteen 
hours before the operation, from which he seemed to suffer 
severely. Notwithstanding this, he rapidly regained his 
health, and remaining well and in good order, he was killed 
on the twenty-eigth day. 

The outer wound was perfectly healed, without the inter- 
vention of the omentum. The bowels had contracted firm 
and extensive adhesions to each other, as well as to the apron- 
like lamella just mentioned, but the lymph by which they 
were produced was quite smooth, organized, and in process 



194 



Gross on Wounds of the Intestines. 



of absorption. The sutures had disappeared from both 
wounds, even to the most minute trace, and the edges of the 
latter, both serous and villous, were continuous with each 
other through the whole of their extent and beautifully united. 
The longitudinal breach was somewhat diminished in length, 
but the other retained its original size. In both, the cicatrice 
presented a smooth, rounded, and slightly elevated appear- 
ance. The mucous membrane was free from puckers, and 
the diameter of the tube natural. 

ExPERiMEKT IX. — Two wounds, each an inch in length — one opening closed 
with Lembert's, the other with the continued suture — recovery. 

In the month of January last, in presence of the medical 
class, I removed a portion of the small intestine from the 
abdomen of a small fat dog, eighteen hours after he had taken 
food, and made two incisions along the convex surface of the 
tube each fully an inch in length. The lips of one of the 
wounds were approximated by three points of Lembert's, 
those of the other by the glover's suture; the contact in each 
being very close and intimate, so as to prevent the possibility 
of fa?cal effusion. Having cleared away the coagulated blood, 
the parts were returned into the abdomen, and ihe edges of 
the outer wound retained by several points of the interrupted 
suture. The animal was kept on light diet for the first three 
or four days, with milk and water for his drink. No untow- 
ard symptoms occurring, and the cure being considered as 
fully established, he was set at liberty on the fifteenth day. 

c. — Oblique Wounds. 

Experiment I. — Oblique wound of tlie small bowel one inch and a half long — 
five sutures — the animal killed at the end of the twelfth day. 

The subject of this experiment, a moderate-sized slut, ap- 
parently several years old, had fasted for twenty-four hours. 
The incision was two feet from the ileo-coecal valve, and ex- 
tended obliquely across the gut from one side of the mesen- 



Gross 071 Wounds of ike Inlestines. 195 

tery to within a few lines of the other for one inch and a half. 
Five sutures, equidistant from each other, were introduced, 
which had the effect, when tied, of accurately closing the 
opening in its entire length. No untoward symptoms super- 
vened upon the operation, and the animal was killed at the 
end of the twelfth day, in good health and condition. 

The outer wound was perfectly healed with a portion of 
omentum prolonged into it. The bowels were entirely free 
from adhesions, except at the seat of the lesion, which was 
covered with a small mass of adherent epiploon of a red color. 
The affected part of the tube was of the natural width, and 
contained a small quantity of mucous and fa.'culent fluid. The 
villous edges were not only in contact with each other but 
firmly consolidated, their continuity being thoroughly re-estab- 
lished, except at the upper extremity of the breach, where 
there was a depression about half a line in diameter. 

Experiment II. — Oblique wound of the small bowel one inch and three-quar- 
ters long — six sutures — the animal killed at the end of the twelfth day. 

This experiment was merely a repetition of the preceding. 
The animal, a small young slut, had fasted for twenty-four 
hours, and the wound, which was one inch and three-quarters 
long, extended obliquely from one side of the mesentery to 
the other. Six sutures were employed at equal intervals. In 
making the outer opening the bladder was accidentally punc- 
tured, followed by a free escape of urine, but no unpleasant 
symptoms afterwards. At the end of the twelfth day, the 
animal, being in good health, was killed. 

The outer wound had healed through the intervention of a 
piece of the omentum, as in the preceding experiment. There 
was no adhesion of the intestines to each other, to the wall 
of the abdomen, to the other viscera, or to the epiploon, ex- 
cept at the seat of the injury. Two sutures remained in the 
wound, one being loose, the other slightly attached. The 
villous edges were separated from each other, without any 
apparent effort at re-union. The bowel, which retained 
its natural width, formed a sort of cul-de-sac just above 



196 



Gross on Wounds of the Intestines. 



and below the wound, seemingly from the vicious attachment 
of the omentum. The villous membrane was healthy, and 
covered with thick, viscid mucus. All the other viscera were 
sound. The wound in the bladder was beautifully cica- 
trized. 

Experiment III. — Oblique wound one inch long — four sutureR — the animal 
killed at the end of the twenty-second day. 

The animal which formed the subject of this experiment 
was very small and not more than nine or ten months old: he 
had fasted for twenty-four hours. The wound, one inch long, 
was situated one foot from the ileo-coecal valve, and closed 
with four sutures. Speedy recovery ensued, or, rather the 
animal did not seem to be affected by the injury, and he was 
permitted to live till the end of the twenty-second day. The 
appearances revealed by the examination so nearly re- 
sembled those ill the last two experiments that it is scarcely 
necessary to specify them. The outer opening had. as usual, 
a process of omentum in it, and a small process was also 
attached to the intestinal wound, which was beautifully cica- 
trized, the continuity of the villous surfaces being completely 
re-established. It had diminished about one-fourth in length. 
The diameter of the tube, however, was natural. The dog 
was in good order. 

F'"xPKniMi:xT IV. — Ohliqiio wound oTiIk^ ilciiiii two inclic?) long — .six sutures — 
recovery— the animal Killed at the end of iIm; thirlcenlli day. 

The dog was old and of middle size, and made much resis- 
tance during the operation, which was consequently somewhat 
tedious. The experiment was witnessed by Dr. Dodson, Dr. 
Richard Ferguson, and several other medical friends. The 
incision, extending obliquely from one side of the mesentery 
to the other, was two inches in length, and closed by six 
points of suture Cfiiiidistant from each other. The dog soon 
recovered from the effects of the operation, and was allowed 
to live until the expiration of the thirteenth day. 



Gross on Wounds of the Intestines. 197 

The outer wound presented nothing unusual. It was pretty 
firmly cicatrized, with a process of omentum projecting 
between its inner lips. The injured bowel, intimately con- 
nected to several neighboring coils by plastic lymph, was dis- 
tended with semi-fluid faacal matter. All the sutures, except 
two, had escaped; the villous edges «f the wound were beau- 
tifully united tliroughout their entire extent, and had an eleva- 
ted, tumified appearance; there was no puckering of the 
mucous membrane, and the cicatrice was less distinctly marked 
than in some of the other cases. The tube retained its 
natural dimensions. It should have been stated that the 
wound had diminished in length fully half an inch. 

10* — Method of Denans. 

In 1826, Mens. Denans, a surgeon of Marseilles, proposed 
the employment of three hollow metallic cylinders, in the 
belief that the serous surfaces of the divided ends of the gut 
could thereby be kept more eflfectually in contact than by any 
other proceeding.* One cylinder is placed into each 
extremity of the tube, which is then invaginated; the other 
cylinder, namely, the third, a little narrower than the rest, is 
next introduced, first into the upper and then into the lower, 
so as to confine and compress the inverted edges, and serve 
as a sort of rod for their support. Two of the cylinders are 
each three lines long, and the other or intermediate one six 
lines; and each end of the gut is inverted about two lines. 
To fasten these cylinders Denans employs several points of 
suture, which embrace the lips of the wound and assist in 
maintaining them in accurate apposition. When the opera- 
tion is completed the ends of the threads are cut ofiT close to 
the peritoneal surface, and the parts returned into the abdo- 
men. The agglutination of the approximated structures is 
soon effected, and the inverted extremities of the bowel, de- 
prived of their vitality by the pressure of the apparatus, rap- 



• Recueil de la Societe de Medecine de Marseille, No. 1. 1826. 
4 



19S 



Gross 071 Wounds of the Intestines. 



idly slough off. The metallic ferules, thus set free, are dis- 
cliarsed along with the faeces. 

The accompanying engravings will more fully explain the 
nature of Denans' apparatus and the manner of securing it 
in the intestinal tube. Figure 1 shows the approximation 




of the two ends of the bowel, with the small cylinders in 
their interior; figure 2, the situation of the middle or long 




Gross on Wounds < f the Intestines. 199 



ferule; figure 3, a vertical section of the bowel, and the pns- 




they have been brought together, and the manner of introdu- 
cing the suture in this stage of the operation. 

It is said that this mode of treatment furnished only one 
successful case in four. In a memoir presented to the Royal 
Academy of Medicine of Paris, Denans states that in the first 
experiment the ferules did not pass out of the bowels until 
seventeen days after the operation. In the second case he 



200 Gross on Wounds of the Intestines. 



wrapped up a small bone in a piece of bread, which was 
given to the dog, and the instruments were voided at the end 
of eight days.* 

Denans, having recently simplified the above method, now 
restricts himself exclusively to the three ferules, which are so 
closely fitted into each other as to obviate the necessity of the 
suture. The new process is thus described by Dr. Charles 
Phillips of Liege. t There is, first, a circular row of springs 
similar to those used as clasps for ladies bracelets. Secondly, 
the outer ferules are of a conical form, the base of each having 
a border a line in extent, which, although covered by the re- 
flected intestine, still holds the springs of the inner ring which 
pass beyond it. By this arrangement the practitioner escapes 
the difllculty experienced in using the suture. When the first 
spring is once adjusted, it is only necessary to reflect as much 
of the bowel as is considered requisite; an advantage which 
prevents the tumefaction of the edges of the wound and the 
formation of a fold at the inside of the ferules, which, it is 
alledged, was the constant cause of the want of success of 
the original method. 

Without having apparently any knowledge of the pro- 
cess of Denans, above described, a very similar practice 
was proposed, a few years ago, by Mons. Baudens, of 
France. His account of it is to be found in his work on 
Gun-shot Wounds, published in 1836. It is certanly less 
complicated than that of his countryman, but whether it 
will ultimately be found to possess any decided advantages 
over it is a circumstance which it is impossible to predict. 
Baudens uses only one metallic ferule with a ring of gum- 
elastic, instead of three, as is in the process of Denans. The 
ferule, moreover, differs from that of Denans in being concave 
on the back, where it is formed into a groove to adapt it 
to the gum-elastic ring which embraces it like a clasp. The 
following is the manner in which the apparatus is applied. 



• London Lancet for 1834-'5, p. 202. 
t Ibid. 



Gross on Wounds of the Intestines. 



201 



The elastic ring is introduced a quarter of an inch within 
the upper end, the lips of which are immediately inverted, 
and consequently folded over the instrument, which thus lies 
in the angle formed by the gut. The forule is next engaged 
in the lower end, to the extent of two lines, when the ring is 
drawn down over it, and the bowel is ready to be reduced into 
its natural situation. Baudens states that he has employed 
this method success''ully on dogs, and that he would not hesi- 
tate, if occasion offered, to resort to it in the human subject. 

A distinguished writer in the Dictionnaire de Medccine ct 
de Chirurgie Pratiques, Mons. L. J. Sanson, in summing up 
the advantages of the different methods of treatment of 
wounds of the intestinal canal, gives a decided preference to 
that of Denans. He seems to think that it will insure more 
perfect apposition of the divided ends, and that it is better cal- 
culated also to prevent contraction of the affected bowel, so 
apt to follow, as he supposes, some of the other procedures. 
He does not, however, support his arguments by any experi- 
ments or observations, and they should therefore be received 
for what they are worth — merelyas so many closet speculations. 
Mr. Lawrence,* in speaking of this method, very justly re- 
marks that "a patient who could survive the infliction of such 
surgery must be endowed with great tenacity of life." 

n. — Method of Reybard. 

The next method that claims our attention is that of Mons. 
Reybard, of Paris, an account of which was published in 
1837, in his "Memoir on Artificial Anus."t The object 
of it, as set forth by the author, is to effect a temporary 
obliteration of the wound and to maintain the bowel in 
strict relation with the wall of the abdomen. For this pur- 
pose a ligature, armed with two sewing needles, is passed 
through a light wooden cylinder, perfectly smooth on its ex- 



* Treatise on Ruptures, p. 356. 

t See Vidal, Traite do Pathologie Externe, T. 4, p. 503.— Velpeau, 
Medicine Operatoire, T. 4, p. 135. 

4 * 



202 



Gross on Wounds of the Intestines. 



terior, and from fifteen to sixteen lines in length by eight 
or nine in diameter. Thus arranged, and having previously, 
like Ramdohr, detached a small piece of the mesentery 
along the concave surface of the tube, the cylinder is intro- 
duced into the intestines, where it is fastened by carrying the 
needles from within outwards through the lips of the wound, 
about a quarter of an inch from its margin. The extrem- 
ities of the ligature, crossed and twisted together, are passed, 
by means of a crooked needle, through the abdominal mus- 
cles, at a short distance from the edge of the»outer opening. 
The double thread is now held by an assistant until the sur- 
geon has reduced the bowel; when, taking it in his left hand, 
he pulls it, and satisfies himself that the injured part is in 
exact apposition with the abdominal parietes. The operar 
tion is completed by separating the ligatures, and tying 
them over a small compress lying parallel with the inner 
lip of the wound. In an experiment performed after this 
method the sutures were cut away at the end of forty-eight 
hours, and the following morning the wooden cylinder wa» 
expelled along with tlie faeces.* 
The nature of this operation 
will be more fully understood 
by a reference to the engravings. 
Figure 1 represents the wooden 
cylinder. 



Figure 2 is a longi- 
tudinal section of the 
bowel with the cylin- 
der fastened by the 
ligature. 




Vidal, op. cit. T. 4, p. r)03. 



Gross 071 Wounds of the Intestines. 



203 



Fig. 3 shows the appearance 
of the parts ready to be returned 
into the abdominal cavity. 




3 



I 



Not having repeated the experiment of Reybard, I can- 
not speak, of it from personal observation. It appears to 
me, however, to be entirely too complicated, to say nothing 
of the danger which must necessarily arise from the presence 
of a foreign body, such as he suggests, and which, it may 
be supposed, might easily be retained in the alimentary ca- 
nal, causing severe, if not fatal, inflammation, ulcerative 
absorption, or insurmountable obstruction to the passage of 
the faeces. It has, moreover, I believe, never been em- 
ployed in the human subject, and it is obviously nothing 
but a modification of the process of Duverger, Sabatier, and 
other surgeons, who recommend the use of a piece of 
trachea, or other hollow body. Such a proceeding is en- 
tirely too mechanical, and would have been better suited to 
the dark ages than it is to the nineteenth century. 

12. — Method of Amussat, Thomson, Choisy and Beclard. 

As if there were no end to the devices of surgeons 
for the cure of wounds of the intestines, Professor Amus- 
sat, of Paris, has recently proposed another, apparent- 
ly highly ingenious, which deserves to be mentioned here 
more on account of its novelty than from any probability 
that it will ever be employed in the human subject. Like 
that of Lembert, Denans and Jobert, its object is to plac« 
the two serous surfaces in contact with each other, to facili- 
tate the adhesive process, and prevent the effusion of 
stercoraceous matter. The idea originally suggested itself 



204 Gross on Wounds of the Intestines. 



to Amussat from observing, on repeating the celebrated 
experiment of JVIr. Travers of encircling the bowel with 
a ligature, with what rapidity the continuity of the tube is 
re-established at the seat of the constriction, and how little the 
operation interferes with the comfort of the animal, or the 
transmission of the feEces. The apparatus which he was led 
to employ in the first instance was simply a piece of elder- 
tube, half an inch long, with a narrow central groove, 
and a diameter somewhat less than that of the intestine. 
This being introduced into the divided ends of the gut, with 
the precaution of making the lower overlap the other, as in 
the operation of Chopart and Desault, a ligature was applied 
around the parts corresponding with the groove, and drawn 
with sufficient tightness to cause their strangulation. The 
result, however, was unsuccessful. The adhesions, from the 
imperfect approximation of the serous surfaces, failed to ac- 
quire the proper degree of solidity, and hence, when the con- 
stricted parts were detached, the edges of the wound separa- 
ted from each other, and the animal promptly perished from 
the effects of faecal effusion. 

To obviate this accident, Amussat applied to each end of 
the elder-tube a small conical ferule, which he fastened by 
means of a small strip of adhesive plaster, the base of the 
one being turned towards that of the other. By this arrangement 
he obtained a deep groove, instead of a superficial depres- 
sion, as in the other contrivance. Two ligatures, six inches 
long, each passed through a straight needle, and placed oppo- 
site each other on the edge at tlie truncated top of one of the 
ferules, complete the apparatus by which the strangulation is 
effected. Thus arranged, the operator introduces the elder- 
tube into one of the ends of the bowel, where it is secured 
by passing the needles fiom within outward through its tunics. 
The other extremity, held open with several forceps, is then 
transfixed with both needles together in the same direction, 
an inch from the lip of the wound, when by means of the 
two threads tlie intestine is gradually drawn over the remain- 
der of the foreign body, or, rather, high enough to overlap 



Gross on Wounds of the Intestines. 



205 



the other portion to the extent of a few lines. A waxed cord 
is now applied around the central groove of the apparatus, and 
drawn with sufficient firmness to strangulate the parts which 
it embraces. Any redundant substance beyond the cord is to 
be removed with the scissors, otherwise it will interfere with 
the union of the serous surfaces, the grand object of the ope- 
ration. In a few days the constricted parts slough, and the 
apparatus, being thus set free, is expelled along with the 
fseces. 

Dr. Charles Phillips, to whom I am mainly indebted 
for this account of the above method, states that it will 
prove successful in four cases out of five, when performed 
with proper precaution. I have not deemed it necessary to 
repeat it on any of the inferior animals, from a conviction 
that it is obnoxious to the same objections as the process of 
Denans, without any compensating advantages. Like the 
operation of Ramdohr, of which, after all, it is merely 
a modification, it requires a previous separation of the 
mesentery, to facilitate the invagination of the upper into 
the lower end; to say nothing of the complicated nature of 
the apparatus, which cannot always be obtained on the spur 
of the moment, and which few practitioners will keep on 
hand in expectation of such an occurrence. 

Soon after the above method was made public. Dr. Alex- 
ander Thomson, of Paris, suggested certain modifications in 
the construction of the apparatus, which, however, have only 
been employed, I believe, on the dead subject. It is impos- 
sible, therefore, to say how they might answer in the living. 
The tube, as improved by Thomson, consists of two pieces, 
instead of one, which are joined together by an ebony ring, 
a third of an inch long. The base of each tube is hollow^ and 
marked by a groove two lines in depth by one and a half in 
width. When united, they present a ridge of two or three 
lines. "The moveable cone is pierced with two holes at its 
border for allowing the introduction of two ligatures. Two 
other waxed threads pass through the substance of the tube, 
upon which the other cone is fixed. The end of the groov« 



206 Gross on Wounds of the Intestines. 

formed by the union of the two cones is made somewhat 
rough, for the purpose of keeping a more firm hold upon the 
intestine. The moveable cone is fixed upon a handle, which 
extends about three quarters of an inch beyond its truncated 
extremity. At the middle of the handle is a small perma- 
nent stud, for the purpose of holding the ligatures which are 
coiled around it. The extremity of the handle serves to open 
a free passage into the intestine, until it has reached two- 
thirds of an inch beyond the base of the cone fixed upon the 
said handle. Close to the stud are two steel arms, furnished 
with hooks and springs for securing the intestine. A ligature 
is then placed over the groove in the base of the cone, and 
tightened so as to produce strangulation of the intestine, 
the operator cutting off a portion of the extremity beyond the 
constricted part. The two ligatures are then loosend, by 
which the cone is set at liberty, a needle is put on each, and 
they are passed through the strangulated portion of intestine. 
The same method having been adopted with respect to the 
other end of the intestine, the two cones are then united in 
such a way that the ligatures applied for fixing them may be 
in immediate contact. They are tied, and cut off near the 
knots, and the intestine is returned into the abdomen."* 

Another modification of Amussat's method was proposed 
by Mons. Choisy, in a thesis which he presented to the Fac- 
ulty of Paris, in 1837, for the degree of doctor of medicine. 
It consists simply in invaginating the divided bowel, and 
tying it over a piece of trachea. In performing the operation 
the foreign body is introduced into the superior extremity, 
where it is fastened by the glover's suture, after which the 
thread is carried from within outwards across the inferior end, 
the latter being thus made to cover a portion of the former. 
The ligature is then applied around the parts, as in Amussat's 
process, and drawn sufficiently tight to eflfect their strangula- 
tion, t Choisy has performed this operation several times 



* London Lancet for 1835, p. 204. 

t Vclpcau, Medccine Operatoire, T. iv, p. 139. 



Gross on Wounds of the Intestines. 



207 



successfully upon dogs, but whether it has been repeated by 
other surgeons I have not been able to learn. 

Beclard, author of the "Elements of General Anatomy," 
suggested, many years ago, a mode of treating wounds of the 
intestinal canal, which, from the success that attended it in 
some of the inferior animals, he thought might be advantage- 
ously applied to the human subject.* It is certainly much 
more simple than that of Amussat, or the modifications of it 
by Thomson and Choisy, and if I could be induced to employ 
any process of the kind, I should unhesitatingly give it the 
preference. The method under consideration consists in in- 
troducing one end within the other, without the intervention 
of any foreign body, and in encircling them with a ligature 
drawn with moderate firmness. The serous surfaces are thus 
brought into close apposition with each other, and the cord, 
cutting its way through the coats of the intestine, falls in a 
few days into the tube, where it is discharged along with the 
f.uces. 



Such is an accurate and impartial account of the various 
and diversified methods of treatment of wounds of the intes- 
tinal canal. Of the estimate to be placed upon them, I have 
already expressed my opinion, excepting in a few instances, 
where the facts I have presented are competent to speak for 
themselves. My conviction is that there are but two sutures 
which should ever be thought of in the managemeut of this 
class of injuries, namely, the continued and the interrupted, 
with the modification of the iatter proposed by Lembert. The 
manner of executing them has been already explained, and 
it is not necessary, therefore, to say any thing further on the 
subject in this place. 

Whichever of these sutures be employed, the operator should 



« Ch^lius, Traite de Chirurgie, T. i, p. 176. Paris, 1835. 



208 



Gross on Wounds of the Intestines. 



never lose sight of the important principle of closing the 
opening in the bowel in such a manner as to prevent the 
escape of fascal matter. By guarding against this occurrence, 
the patient will run comparatively little risk of perishing 
from peritoneal inflammation. When the wound is trans- 
verse, and involves the whole cylinder of the tube, I should 
prefer the continued or common interrupted suture to* the 
method of Lembert, especially in young subjects, in whom 
the canal is very narrow, or in persons in whom the bowel 
is over-loaded with faecal matter at the moment of the 
injury. In a case of this kind the inverted edges might 
occasion serious obstruction, from the manner in which 
they project into the interior of the canal. To longitu- 
dinal and oblique wounds, particularly the former, the expedi- 
ent of Lembert is admirably adapted. The operation is very 
simple, the sutures easily retain their hold, and the divided 
edges are more speedily re-united than by any other method. 

In reflecting upon the results of the experiments which 
have been offered in illustration of the use of the above 
sutures, it should not be forgotten that an operation which 
is perfectly successful upon an inferior animal, may, 
when performed upon the human subject, be followed by the 
worst consequences. In the one, disease is exceedingly rare; 
in the other, it is not only frequent, but capable of assuming 
a vast variety of forms, and of sapping the foundations of life 
when least expected. In the one, peritoneal inflammation is 
not only uncommon, but, when developed, seldom attains any 
considerable height; in the other, it is not only easily excited, 
but extremely apt to terminate fatally. Aware of these facts, 
the surgeon should always scrupulously guard against the 
infliction of unnecessary injury; the stitching should be done 
as gently as possible; and all rough manipulation should be 
carefully avoided. After the parts have been reduced the 
external wound should be closed by several points of suture, 
and every effort made to avert peritoneal inflammation, the 
great source of danger in injuries of this kind. 

It has been alleged that longitudinal do not unite with the 



Gross on Wounds of the Intestines. 



209 



same facility as transverse wounds. "There is a curious dif- 
ference," observes Sir A. Cooper,* "in the facility with wliich 
a longitudinal and a transverse wound of the intestine unite. 
It lias been already shown that the transverse heal readily, 
but with respect to the longitudinal, they have a contrary 
tendency." In illustration of this assertion, he cites two ex- 
periments by Dr. Thomson, of Edinburgh, in which death oc- 
curred from the extravasation of fcecal matter, in less than 
forty-eight hours. The wound in each was an inch and a 
half long, and closed by four interrupted sutures,' with the 
precaution, in one, of sewing up the intestine with a fine 
thread. In an experiment performed by himself, in which 
the incision was of the same length as in the preceding 
cases, and in which he had recourse to the continued suture, 
the animal recovered. 

My own experience by no means coincides with that of 
the great English surgeon. We have already seen that, in 
the twenty-seven experiments above detailed, there were 
only two deaths, notwithstanding the great extent of the 
wound in some of them. I have no reason to believe, as Sir 
A. Cooper apprehends, that the sewing up of a longitudinal 
wound produces a greater degree of constitutional irritation 
than that of a transverse one; at all events, I have never 
witnessed any result of the kind. The experiments which 
he adduces from Dr. Thomson in support of his opinion 
were evidently not executed with the requisite precaution. 
A wound an inch and a half long cannot, as a general prin- 
ciple, be returned with safety into the abdomen with only 
four interrupted sutures; faecal effusion would be almost in- 
evitable, especially if the canal happened at the time to be 
loaded with ingesta, or if the animal were permitted to take 
much drink or food after the operation. In the second ex- 
periment the dog died, not because the parts had not been 
duly approximated in the first instance, but because tiie su- 
tures, interrupted as well continued, had lost their hold, and 



* Anatomy and Surgical Treatment of Hernia, p. 51. 

5 



210 Gross on Wounds of the Intestines. 



thus allowed the wound to gap, and the fa;ces to escape into 
the peritoneal sac. In the experiment performed by Sir A. 
Cooper himself, in which the edges of the solution of con- 
tinuity were secured by the uninterrupted suture, no effusion 
could occur, and the consequence was that the animal quick- 
ly recovered. 

The conclusion, therefore, which I would draw from my 
researches is, that longitudinal wounds, instead of uniting 
less easily than transverse, generally adhere with more facili- 
ty, that they do not produce a greater degree of constitu- 
tional irritation, or local disturbance, and that they are not 
more liable, if as much so, to be followed hy contraction of 
the caliber of the tube at the seat of the injury. The same 
remarks I consider as applicable to oblique wounds. In nine 
cases of this kind, treated by the continued and interrupted 
suture, or by the method of Lembert, there was not a single 
death, any unusual symptom, or any diminution of the 
affected cylinder. 

VI. — Partial and Complete Division of the Inteslines. 

In operating for sphacelated hernia it occasionally happens 
that the constricted bowel contains a small aperture, caused 
either by the strangulation, or by the efforts which the sur- 
geon is obliged to make to effect the reduction. The gut 
may also be accidentally wounded by the knife in attempt- 
ing to divide the stricture, by neglecting to draw down the 
sac, and holding up the abdominal muscles. A number of 
examples of this kind arc mentioned by authors. One is 
recorded by Mr. Lawrence in his Treatise on Ruptures, and 
another, which occurred in the practice of Cloquet, is 
cited in a previous part of this inquiry. When tliis acci- 
dent happens, and the aperture is small. Sir Astley Cooper 
advises a treatment somewhat different from that which 
is proper when the tube is mortified in its entire cir- 
cumference. Instead of excising the affected parts, and 
bringing the edges together by means of the suture, the sur*- 



Gross on Wounds of the Intestines. 211 

geon should pinch up the margins of the opening with a 
pair of forceps, and then include them in a fine silk 
ligature, -drawn sufficiently tight to divide the mucous mem- 
brane. The bowel should afterwards be returned to the 
mouth of the sac, and the case managed upon general princi- 
ples. The preternatural orifice must not be more than three 
or four lines in diameter, otherwise it will not only be diffi- 
cult to prevent the ligature from losing its hold, but the ope- 
ration will be likely to be followed by undue and injurious 
contraction of the gut. 

The following experiments and cases will exhibit this ope- 
ration in a more forcible point of view. Of the latter, two oc- 
curred in the hands of Mr. Lawrence, the other in those of 
Sir Astley Cooper, with whom I believe the practice origi- 
nated, and to whom surgery is indebted for some of its most 
ingenious and substantial improvements. 
. ExPEuiMENT I. — Having opened the abdomen of a small 
slut, and exposed a fold of the ileum, I made an incision, 
half an inch in length, along its convex surface, and secured 
it by means of a strong silk ligature tied firmly round its 
sides. Some difficulty was experienced in preventing the 
thread from slipping; it was drawn with considerable firm- 
ness, and when the ends were cut otf it was found to be 
nearly concealed from view by the apposition of the serous 
surfaces. The bowel was then returned, and the outer 
wound closed in the usual manner. The animal did not ap- 
pear to mind the operation, which was soon over, and she 
was permitted to live until the ninth day. It is unnecessary 
to mention all the particulars of the post-mortem examina- 
tion. Suffice it to say that the small intestines were slightly 
agglutinated to each other and to the omentum., and that the 
latter projected into and assisted in closing the outer wound. 
The bowel at the seat of the injury was remarkably firm, and 
presented numerous red points. The ligature had disappear- 
ed, and the edges of the wound were about three lines apart 
at their centre, without any contraction of the caliber of the 
tube. The bottom of the wound was consequently formed 



2*12 



Gross on Wounds of the Intestines. 



by a neighboring convolution protected only by a thin layer 
of lymph of a yellow-greenish appearance, from the admix- 
ture evidently of bilious matter. 

Experiment II. — The incision in this experiment was 
transverse instead of longitudinal, but of the same extent as in 
the preceding. It was situated in the small bowel, about two 
feet from the ileo-coecal valve, and the difficulty experienced 
in encircling it was still greater than in the former case. One 
end of the ligature being cut oil' near the peritoneal surface, the 
other was brought out at the external wound, which was closed 
in the usual way. The animal, a small pup, soon recovered 
from the shock of the operation, and was killed twenty-three 
days after, the ligature having been detached towards the end 
of the first week. The outer wound was completely cica- 
trized, with a process of omentum adherent round its mar- 
gins, as well as to the convolutions of the small intestines. 
The latter were strongly united to each other at several points, 
particularly at the seat of the injury, which was almost per- 
fectly repaired, the mucous membrane being deficient 
over a space not exceeding the diameter of a split pea. The 
bowel retained its normal dimensions, and the animal was 
in .good condition at the time he was killed. 

Case I.* — John Shall, sixty years of age, was admitted 
into St. Bartholomew's Hospital, on the 2d of Novembei 
1826, with strangulated inguinal hernia. The tumor was 
hard and painful, the abdomen was tender on pressure, and 
there was a sense pf tightness across the navel, with con- 
stant nausea and occasional vomiting. The pulse was small 
and frequent, and the symptoms in all respects urgent. All 
attempts to replace the parts by the taxis having failed, Mr. 
Lawrence proceeded to operate eight hours after the bowel 
had come down. The swelling contained a portion of small 
intestine in front with a large mass of omentum behind, and 
the stricture was caused by the neck of the sac, which encir- 
cled the protruded tube like a tight cord. On withdrawing 



* Lawrence's Treatise on Ruptures, p. 301-3. 



Gross on Wounds of the Intestines. 



213 



the intestine gently, an opening M'as discovered in it just 
above the part that had been compressed, and which had 
probably been made by the bistoury in dividing the stric- 
ture. The sides of this aperture, which was very small, be- 
ing held with the dissecting forceps, a ligature was firmly 
tied around it, after which the ends were cut close to the knot. 
A piece of omentum, which had been long protruded, and 
which it was found difficult to return into the abdomen, was 
removed with the knife, and the divided vessels, six or eight 
in number, secured in the usual manner. The integuments 
were brought together by three or four sutures, assisted by 
strips of adhesive plaster. Soon after the operation the 
bowels were evacuated with senna, and blood was twice 
taken from the arm. On the 6th of November the sutures 
were removed from the outer wound, and on the 13th the lig- 
atures came away from the omentum. It is needless to add 
that the patient rapidly recovered. 

Case IL— In another case, in which the bowel was 
wounded, Mr. Lawrence * pursued the same method. 
It was a large enterocele with the intestines greatly disten- 
ded and the abdomen so very tense that it was difficult to re- 
place the parts and prevent them from re-descending. The 
symptoms were not relieved by the operation, and death 
ensued within two days. The ligature was completely 
covered by a thin smooth layer of lymph, and so concealed 
that there was difficulty in finding it: the small wound in 
the bowel was closed. 

Case III. — Joseph Curtis, a butcher, twenty-one years of 
age, was brought into Guy's Hospital, on the 9th of Decem- 
ber, 1808. He had a tumor in his left groin, which was 
very hard and tense, and gave considerable uneasiness on 
pressure. Along with this was violent pain in the stomach 
with vomiting of green bilious matter. Various attempts 
were made at reduction, but they all failed, and the opera- 



• Op. cit. 

5 ♦ 



214 Gross on Wounds of the Intestines. 



tion was therefore at once determined upon by Mr., after- 
wards Sir Astley Cooper. About four inches of the small 
intestines were found in the sac, of a dark reddish color, with 
the testicle at the lower part. The stricture, situated at the 
mouth of the sac, was divided in the usual manner; a fluid 
of a yellowish appearance escaped, and on turning up the 
gut an opening was discovered, which was immediately laid 
hold of with a pair of forceps, and tied with a ligature. The 
parts were then returned, and the abdominal wound secured 
by five stitches assisted by adhesive strips. The patient 
bore the operation well, and seemed much better after 
it. For the first ten or twelve days, however, his sufferings 
were severe, but he gradually surmounted them, and was 
discharged cured on the 17lh of January, 1809, a little more 
than three months after his admission.* 

In commenting on this case, Sir Astley Cooper uses the 
following language: "We had the pleasure and satisfaction 
to see the patient completely recovered from an operation, 
the circumstances attending which were remarkable, and 
such as will tend to throw much light upon a subject hither- 
to but little understood." 

The above plan, so happily employed by Sir Astley Cooper 
and Mr. Lawrence, has doubtless been adopted, if not ac- 
tually executed, by numerous other surgeons. "Many years 
ago," says Prof. Gibson,! in speaking of Sir Astley Cooper's 
procedure, "I performed a similar operation in a case of 
hernia, and with equal success." Mr. Syme, of Edinburgh, 
recommends the same practice.t which may now, indeed, be 
considered as being fully sanctioned both by observations on 
the human subject and experiments on the lower animals. 

Such is the treatment which should undoubtedly be pur- 
sued by the surgeon when he meets with an aperture of small 



* The Anatomy and Surgical Treatment of Abdominal Hernia, Part i, p. 
45. Second edition, 
t Institutes of Surgery, vol. i, p. 119. Philadelphia, 1838. 
\ Principles of Surgery, p. 262. Second edition. 



Gross on Wounds of the Intestines. 215 



size in the strangulated bowel. When the gangrene, how- 
ever, involves the entire cylinder of the tube, a different 
mode of management must be resorted to. Under these cir- 
cumstances, the affected parts should either be excised, and 
the edges approximated by the suture; or they should be freely 
opened, and maintained in contact with the abdominal wound, 
to afford a ready outlet to the faeces. The experience of the 
profession has not yet fully determined, I think, which of 
these methods should be adopted to the exclusion of the oth- 
er, or whether both are not occasionally justifiable. Sev- 
eral examples have already been cited in which excision 
was practised with the most complete success. The memor- 
able case of Ramdohr is of this kind. An analogous one is 
recorded by Baudens, and mentioned under the head of 
Lembert's process of sewing up wounds of the intestines. 
The case which occurred ia the hands of Dieffenbach is also 
in point. The sphacelated part was at least three inches in 
length; the whole of which was removed with the knife, and 
the divided extremities secured by suture. The man 
lived nearly a month after the operation, and would have 
completely recovered but for some imprudence in his diet. 
In another case four inches of mortified intestine were re- 
moved, and the patient, a young man, recovered * Many 
examples of a similar description are on record, but it 
is not necessary to refer to them more particularly in this 
place. 

The practice of excision derives support from what is oc- 
casionally witnessed in intus-susception of the intestines, in 
which large pieces of ihe tube are detached without any det- 
riment to life. In my museum of morbid anatomy is a pre- 
paration of this kind, presented to me by my friend Dr. 
Dawson, of Ohio, in which a portion of the colon, twenty- 
nine inches long, was discharged by a child six years of age, 
who, notwithstanding, made a most rapid recovery. This 
patient, as I have been recently informed, is still living and 



* Sir A. Cooper on Hernia, p. 37. 



216 Gross on Wounds of the Intestines. 



in perfect health, three years after the above occurrence. 
Thirty-five cases of a similar nature, collected from the 
writings of different pathologists, have been reported by Dr. 
Thompson of Europe.* The length of the eliminated pieces 
varied from six inches to upwards of three feet: they gener- 
ally involved the whole cylinder of the bowel, and nearly 
all had a portion of mesentery attr.ched to them. In one in- 
Btance there was a mesenteric ganglion, in another a pro- 
cess of omentum. The average duration of the disease was 
between four and five weeks. In twenty-two of the cases 
the evacuated portion appertained to the small bowel, in the 
other to the large, or jointly to this and to the former. The 
coBcum was affected alone in one instance, the colon in two, 
the jejunum in three, the ileum in eleven. 

The following case may be adduced as throwing additional 
light upon this interesting and important subject. It occur- 
red in the practice of Dr. McKeever, of Dublin, and will 
be found recorded in the fourth volume of the London Med- 
ico-Chirurgical Review. 

A young robust woman, after having been in labor for 
upwards of thirty hours, was delivered on the 29th day of 
July, with the crotchet, previously to which a rent had 
taken place high up in the posterior part of the vagina, 
which extended round the neck of bladder, and communica- 
ted freely with that viscus. On the following day, in the 
afternoon, one of the attendants observed a shining sub- 
stance hanging from the external parts, which was found, on 
the fifth of August, when Dr. McKeever first visited her, 
to be nearly a yard and a half pf her small bowel coiled 
up under her, black, apparently putrid, and full of openings. 
Her belly at this time was much swollen, and excessively 
painful; her stomach rejected even the mildest articles of 
diet; the bowels were still obstinately confined; the pulse 
was small, intermitting and tremulous; and her countenance 



•Edinburgh Medical and Surgical Journal, Oct. 1835. — See also tho author'i 
Heinenta of Palliological Anatomy, vol. ii., p. 360. 



Gross on Wounds of the Intestines. 



217 



was pallid and ghastly: in short, she had every appearance 
of being in a moribund state. It being too late to return the 
parts, the treatment was merely palliative. On the follow- 
ing day, the protruded portion of the intestine had a soft 
doughy feel, was more shrivelled, and, instead of being black 
and livid, it was of a dirty ash-color. The constitutional 
phenomena were as before. On the seventh day the mortified 
parts, measuring precisely three feet and eleven inches, were 
detached, and the woman was nearly free from alarming and 
distressing symptoms. The vomiting and hiccough had ceased, 
her pulse was regular and of good strength, the counten- 
ance much improved, and the abdomen, though still much 
swelled, less tender to the touch. She hud also a copious 
discharge of fceces by the vagina, being the first alvine evac- 
uation she had since her delivery. 

From this lime she gradually mended. Her countenance 
improved, the secretion of milk became abundant, and the 
excrementitious matter was of a healthy color, smell and 
consistence. Three years after the occurrence of the acci- 
dent, she could walk a dozen miles without inconvenience, 
and had become fat. For two years after her confinement 
she had no discharge whatever from the rectum, the residue 
of her food being altogether voided by the vagina. About 
the end of that period, however, she was attacked with vio- 
lent bearing-down pains, accompanied by tenesmus, and 
after half an hour's severe suffering, she passed b}' the natu- 
ral route a large quantity of dark, pitch-colored fasces, of 
the consistence of balls of firm wax. It is unnecessary to 
give further particulars. Suffice it to say that the woman 
was afterwards safely delivered of a small child, and that 
the faeces have ever since been discharged in the natural 
way. 

The above case requires no comment. It is in all re- 
spects one of the most extraordinary on record, and affords 
convincing proof that injuries attended with the loss of large 
portions of the alimentary canal, are not necessarily fatal. 
Coxe's Museum contains a case, from the London Philosoph- 



218 



Gross on Wounds of the Intestines. 



ical Transactions, of a boy who had his bowels protruded, 
and fifty-seven inches cut off by a cart, who, nevertheless, 
recovered his health in six or seven months. 

To these observations I add the following experiments as 
having a direct bearing upon the subject under considera- 
tion. 

Experiment I. — From a small but full grown dog two inches 
and a half of the ileum were removed, near its junction with 
the large bowel, after which the edges of the wound were 
brought together with six interrupted sutures, introduced 
equidistant from each other, and made with a common needle 
and fine silk. The extremities of the ligatures were cut off 
close to the knots, and the parts being restored to their natu- 
ral situation, the abdominal wound was secured by several 
stitches. Several ounces of blood — perhaps four or five — 
were lost during the operation, and the animal appeared to be 
somewhat faint. In the evening he was dull and drowsy, 
and indisposed to move about; but in the morning he was 
observed to be better, and from that time he rapidly recover- 
ed. Four months afterwards, being in good health, and the 
outer wound perfectly healed, he was killed. Externally the 
bowel was smooth and natural, with no trace whatever of the 
former injury, excepting the attachment of a very small pro- 
cess of the epiploon. Had it not been for this circumstance 
it would have been exceedingly difficult, if not impossible, to 
find the seat of the wound. The mucous membrane was of 
the natural color; there was not the least contraction of the 
tube; and the situation of the breach was indicated merely 
by a very narrow oblique lin^ or depression. No adhesions 
existed between the bowels or between them and the walls of 
the abdomen. See pi. fig. 8. 

Experiment II. — In a second experiment five inches of the 
ileum were excised, and the lips of the breach maintained in 
contact by seven interrupted sutures, with the ends cut oflT 
close to the serous surface. The divided mesenteric vessels 
bled so freely during the operation that it became necessary 
to secure them with a ligature, which, however, lost its hold 



Gross on Wounds of the Intestines. 



219 



in attempting to replace the bowel. The dog, which was 
small, and not more than about a year old, died in thirty hours 
from the protrusion of eighteen inches of the small bowel, 
which was lacerated near its middle, of a dark livid complex- 
ion, and apparently sphacelated. Externally the wounded 
surface was slightly coated with plastic lymph, as well as par- 
tially covered with adherent omentum, and the parts above 
and below were of a deep rose tint. The mucous lining im- 
mediately around the seat of the injury was of a purple color; 
and there was a small coagulum where theligature had slipped 
from the mesenteric vessels. No fajcal matter had found 
its way into the peritoneal cavity; the sutures had retained 
their situation; the lips of the wound were in contact with 
each other, both internally and externally; and it was obvious 
enough that the animal had perished from the protrusion and 
consequent inflammation of the ileum. The cause of this 
accident was tiie premature detachment of the stitches in the 
outer opening. 

Experiment III. — Finally, in a third experiment the por- 
tion of ileum cut away measured eleven inches and a half. 
The edges of the divided extremities were brought together, 
and maintained in apposition by means of the continued su- 
ture, made with fine sewing silk, v/ell waxed, and armed with 
a delicate needle. Several of the mesenteric arteries were 
surrounded with a ligature, which was brought out at the ori- 
fice in the wall of the abdomen. The dog, large, and several 
years old, became sick soon after the operation, which was 
both tedious and painful; at the expiration, however, of 
twenty-four hours he took food, appearing lively and even 
cheerful. He continued thus until the eighth day, when he 
was observed to be seriously indisposed, and early on the 
following morning he died. 

On inspection, the inner lips of the wound were found to 
be in a soft, pouting condition, slightly covered with mucous, 
but no faecal matter, and without any perceptible attempt at 
restoration; the suture was still in its place. Three folds of 
the intestines were glued together at the seat of the injury, 



220 



Gross on Wounds of the Intesstine. 



and the parts there were somewhat red, as the effect of in- 
flammation. Numerous petechial spots were observed upon 
the parietal portion of the peritoneum; and the serous and 
muscular tunics, both of the small and large bowel, presented, 
in several situations, a singularly lacerated aspect. The vil- 
lous membrane in the vicinity of the wound was softened, 
and covered with a considerable quantity of thick, ropy mu- 
cus. The stomach and other organs were healthy. There 
was no obstruction from fascal matter, or any contraction of 
the caliber of the tube. 

It will be seen from the foregoing statements that only one 
of these experiments terminated favorably, namely, the first, 
in which the excised portion of intestine amounted only to 
two inches and a half. In the second, the animal might pos- 
sibly have recovered had not the sutures of the external 
wound given way, and thus permitted the escape of tho 
bowel, which was subsequently lacerated, and seized with 
violent inflammation. In the third experiment, in which 
nearly one foot of the intestine was removed, the dog seem- 
ed to suffer severely from the shock of the operation; and, 
although re-action soon took place, he finally perished, on the 
ninth day, from the effects of his wounds. How the lacera- 
tion of the serous and muscular tunics of the large and small 
bowels was induced, it is impossible to conjecture; nor is it 
easy to determine how far, or in what degree, it influenced 
the fatal event. 

In two experiments of this kind by Dr. Smith of St. Croix, 
the results were of the most gratifying nature. In one, the 
excised portion of the small intestine — probably the ileum — 
measured two inches; in the other, two inches and a half. la 
both cases he made use of four interrupted sutures, placed at 
equal intervals, with the ends cut off at the knots. The ani- 
mals were killed on the twentieth day, when the union was 
found to be so perfect that it was difficult to discover the seat 
of the injury. In one, all the ligatures were detached; in the 
other, one still remained. 

The results of these observations and experiments are in 



Gross on Wounds of the Intestines. 



221 



the highest degree interesting, as they tend to establish an import- 
ant practical precept. Cases occasionally occur in which the 
bowel is so much injured, cut, bruised or lacerated, as to be 
inevitably followed by gangrene, if the parts be not promptly 
excised, and treated in conformity with the principles here 
laid down. In extensive mortification from strangulation it 
becomes, as we have already seen, a question whether the 
affected portion should be removed by the knife, or the sepa- 
ration of it be intrusted to the efforts of nature. In the lat- 
ter case, even supposing that the patient would run no risk 
from the effusion of faecal matter into the peritoneal sac, he 
would still be subjected to that most loathsome of all dis- 
eases, an artificial anus; in the former, the injured structures 
would be placed in the same relations as those of a common 
incised wound, and the chances of recovery would therefore 
be incomparably greater. In intus-susception, where one por- 
tion of bowel fails into another, and where the included piece 
is finally detached by sloughing, nature performs the same 
operation precisely that the surgeon does under the circum- 
stances, in question, with the difference merely that she is 
much longer in accomplishing her object; which, however, is 
not less effectual in the end. The practice, then, would seem 
to be sanctioned, not only by reason and analogy, but by 
experiments on the inferior animals and observations on the 
human subject. 

Would it be good practice, in extensive longitudinal or 
obliuqe wounds, to exci.se the affected part, and treat the case 
like one in which the tube is completely divided in the first 
instance? My opinion is that it would, especially where 
the opening is more than two inches in length. My reason 
for this conclusion is, that wounds of this extent require an 
unusually long time to heal, that ihe canal may become perma- 
nently contracted, and that the adhesive process is rarely so 
perfect as when the aperture is smaller. In addition to this, as 
was before remarked, there must necessarily be more irritation 
from the great number of sutures, to say nothing of the immedi- 
ately bad effects occasioned by the protracted manipulation 
6 



232 



Gross on Wounds of the Intestines. 



necessary to apply them. In an experiment, the particulars of 
which are detailed in another page, and in which the wound was 
three inches and a half long, death was evidently produced 
by the ulcerative action of the adventitious substance which 
formed the bottom of the opening, and which was conse- 
quently in direct contact with the contents of the tube. The 
abnormal aperture was nearly the size of half a dime. The 
animal lived till the end of the thirteenth day, and was con- 
sidered entirely out of danger, when the perforation occurred 
which led to his death. Altogether eleven sutures had been 
used, of which only two remained. This case, although a 
solitary one, is sufficient, I think, to show the impropriety of 
employing so many sutures, or, rather, tlie inexpediency of 
attempting to save the affected part in extensive injuries of 
the intestinal canal. 

Littre, an old French surgeon, was of opinion that the best 
])ractice, when the bowel is completely severed, whether by 
accident or mortification, is to bring the superior end out at 
tiie external opening, for the purpose of establishing an artifi- 
cial anus, and to return the other into the peritoneal cavity, 
having previously tied it to effect its obliteration. The inevit- 
able result of such a procedure would be to consign the pa- 
tient to a miserable existence, as it would deprive him of all 
chance of recovery, and leave him with an infirmity that 
renders him disgusting to himself and to those around. It 
really becomes a question, as has been justly observed by Mr. 
Lawrence, whether life itself be desirable, if burthened with 
the discharge of faeces through the groin or some other region. 

A more rational and less objectionable metliod was pro- 
posed by La Peyronie. It consists in passing a double 
thread behind the wound through a fold of the mesentery, 
and retaining the ends of the bowel at the outer aperture, 
by fastening the extremities of the ligature to the surface 
of the abdomen with adhesive strips. This operation, like 
that of Littre, is always followed by an artificial anus; 
but, instead of being rendered incurable, as necessarily 
happens in the latter case, it generally yields to judicious 



Gross on Woiinds of the Intestines. 



223 



management. Several examples in which this expedient was 
successfully resorted to are on record. I select the following 
as one of the most recent and interesting. 

A man at the assault of Cairo, in 1799, was wounded by a 
ball in the abdomen, which entered on the right side, and 
perforated the ileum. The two ends of the bowel were rup- 
tured, separated from each other, and tumefied; the superior 
being turned upon itself, so that it looked like the prgepuce in 
paraphyinosis, and caused complete obstruction of the tube. 
By four small incisions with the crooked scissors, Baron Lar- 
rey, the reporter of the case, divided the neck of the strangu- 
lated intestine, and restored it to its proper situation. He 
then passed a ligature into the portion of the mesentery cor- 
responding with the two ends of the canal, which he returned 
as far as the edge of the wound, which he had previously 
taken care to dilate. After dressing the parts, he waited the 
result. For the first few days the symptoms were unpro- 
mising, but they gradually abated in severity, the alvine 
evacuations daily improved, and in about two months the 
ends of the ileum were in apposition and ready to adhere. 
The wound was afterwards dressed with a plug, according to 
the ingenious plan suggested by Desault, and the soldier ulti- 
mately left the hospital completely cured.* 

In a case mentioned by La Peyronie himself, the patient was 
about sixty-three years of age, and the bowel was aftected 
with mortification from strangulation. The whole of the 
sphacelated part was cut away, and a thread passed through 
the mesentery, by which the ends of the gut were kept in 
apposition with the external opening. The fa;ces were void- 
ed through the artificial anus until the thirty-sixth clay, when 
they began to resume their natural route, and in four months 
the ulcer was completely healed. Subsequently, however, an 
abcess formed at the seat of the cicatrice, followed by a new 
rupture.f 



' Memoirs of Military Surgery, translated by Dr. Hall, vol. i, p. 'A'H). 
t Boyer, Traite des Maladies Chirurgicales, T. viii, p. 136. 



224 



Gross on Wounds of the Intestines. 



The practice commonly pursued by surgeons, when the 
bowel is mortified in its entire cylinder, is to pull it gently 
down, and make a large incision into it, to afford a free out- 
let to the faeces. The artificial anus thus established gradually 
diminishes in size, and after some months disappears, the 
alvine matter, in the meanwhile, resuming its natural route. 
Upon the propriety or impropriety of this practice it is not 
necessary here to insist. Further observation can alone 
settle the question. When there is much inflammation be- 
yond the sphacelated parts, if would probably be wrong to 
pursue any other treatment; if, on the other hand, the tube is 
nearly, or quite sound, I should not hesitate to excise the 
mortified structures, and to approximate the ends by the 
suture, in the manner already explained. 



JSelecttous from American auli jForctgn Souvnals, 



Engorgement of the Uterus. — In a pamphlet published by 
Doctor Clement Ollivier, of Angers, on the treatment of pro- 
lapsus uteri, he speaks strongly against the use of differently 
shaped pessaries, which are employed indiscriminately, with- 
out paying attention to the cause of the prolapsus, which, 
according to Dr. Ollivier, is nothing more than an engorge- 
ment. Thence arise the symptoms which are constantly 
observed, and which are attributed to any cause other than 
the presence of a foreign body, and its contact with a painful 
and inflamed surface. 

Ollivier considers that one of the most frequent causes 
of this afl'ection in young girls, with whom it is very rare, is 
masturbation. He says, that one of the most frequent causes 
of chronic engorgement of the uterus in virgins, or women 
who do not have any communication with men, is masturba- 
tion, which, by gradually inducing disorder in the uterine 
functions, gives rise at first to spasm of the organ, which 
affects the secretion of the menstrua; on the other hand, this 
excitement, if frequently repeated, finally brings on a more 
or less intense sanguineous congestion, which gives rise to a 
kind of impermeability of the uterine parenchyma, caused by 
a slight inflammatory affection; then the dysmenorrhtea, at a 
later period, becoming habitual, induces amenorrlioea, which 
ultimately determines more dangerous diseases. Sterility is 
always an inevitable result, unless the diseased state of the 
uterus being arrested, allows those portions of the viscus 
which continue healthy to perform their functions; the cata- 
menia may then reappear, but are almost always accompa- 
nied by uterine colics; the matrix may recover its powers of 
conception, but during gestation a period arrives when the 
uterus, not being able to enlarge freely, on account of the 
inflammatory action it has undergone before conception, re- 
6 * 



226 



Engorgement of the Uterus. 



acts upon the product it contains, and almost always deter- 
mines an abortion; in this way the pregnancies of women 
affected with morbid conditions of the uterus almost always 
terminate. 

Masturbation, in causing a disordered condition of the 
entire uterus, produces more frequently an engorgement of 
the body of the organ rather than of the neck, whilst an 
exactly contrary condition obtains in women who have con- 
nection with men. In virgins the affection of the body of the 
uterus is more frequently found, that of the cervix uteri more 
rarely. 

Ollivier mentions, among other causes of engorgement 
of the uterus, the irritation of the sexual organs by primary 
connection, a cause of irritation of the organ the more dan- 
gerous, that it has hitherto escaped the notice of medical 
men, either because they do not attach sufficient importance 
to it, or because women conceal from them the knowledge of 
their illness, notwithstanding the sufferings they endure. 

The dysmemorrhoea, which almost always follows abortions, 
is the result of an inflammatory engorgement more or less 
considerable, and susceptible of cure; this engorgement is the 
cause of the sterility that follows miscarriages. The fre- 
quency of these inflammatory engorgements observed by the 
vulgar has rendered abortions more dangerous in their eyes 
than a delivery at the full period; when tliey take place during 
the first pregnancy, they are the more ficquently to be attrib- 
uted to a too great sensibility of the uterus, as yet unaccus- 
tomed to the sensations produced by coition. It is this sensi- 
bility which gives rise to consecutive inflammatory symptoms; 
under other circumstances this uterine sensibility causes the 
disorders which precede menstruation. 

Ollivier attributes the sterility which occurs to most women 
in large towns after their first and second labors, to a simi- 
lar cause. The editors of the "Journal de Medicine et de 
Cliirurgie Pratiques" observe, with respect to this opinion, 
that they agree with Ollivier, that the engorgement of the 
uterus may sonu times ))revent conception, but that another 
cause for this pretended sterility in great towns, and Paris 
especially, must be sought for. Considerations of a difFerenl 
kind will explain the small number of children found in fami- 
lies, whose pecuniary means are not in just relation with 
their daily expenses. — Med. Examiner, irom Frovinciul Medi- 
cal Journal. 



Muriate of Ammonia in Hemicrania. — Hydrophobia. 227 



Muriate of Ammonia in Hemicrania. — Dr. Watson, in his 
clinical lectures, thus speaks of the Muriate of Ammonia in 
Hemicrania: 

It is well worth knowing that muriate of ammonia is most 
serviceable in this form of hemicrania. Of the remedial pro- 
perties of sal ammonia very little is known, at least very little 
was so until lately; its efficacy and the mode of administer- 
ing it were first made known to me by an old apothecary of 
this city, who had, in innumerable cases, found it a sovereign 
cure. It should be administered in doses of half a drachm, 
or a scruple, and you will find that where persons complain 
of pain in the jaw and the whole side of the head, the pain 
freely yields to this dose of muriate of ammonia. I may add 
that in Germany this medicine is used in many cases where 
we use mercury, and for the same purposes, as in hepatic 
aflfections, and that it produces the required results without 
any of the inconveniences attending the use of mercury, 

Med. Ex., I'roin Prov. Med. Journ. 



Case of Idiopathic Hydrophobia. — By J. Kimbell, M. R. 
C. S. L. — W. K., aged twenty-four years, of a bilio-lymphatic 
temperament, has, during the last month, suflered from occa- 
sional attacks of palpitation of the heart, occurring generally 
in the night, and invariably followed by profuse perspiration. 
On October 4th, 1841, he rode a distance af fourteen miles, 
and on arriving at the end of his journey at about twelve 
o'clock, A. M., he was seized suddenly with great difficulty of 
breathing, pain over the region of the heart, and painful sen- 
sations over the chest. The paroxysm continued for a few 
minutes, when the dyspnoea and pain gradually subsided; he 
afterwards ate a good dinner, and appeared as well as usual, 
until about eight o'clock in the evening, when all the symp- 
toms returned with greater violence than before, and to so dis- 
tressing a degree did the dyspnoea increase, that there 
af)peared to be imminent danger of suffocation. He was now 
bled to eighteen ounces, but without any manifest leliel', and 
the operation was repeated in three hours to ttie amount of 
six ounces, which had the effect of considerably relieving the 
pain. 

About five, A. M., October 5th, I saw him; he could not 
speak, although conscious of what was passing around him; I 
was informed that he had had violent convulsive movements of 



338 



Idiopathic Hydrophobia. 



the arms, which had lasted nearly an hour, and he now 
appeared to be suffering from a spasmodic constriction about 
the glottis and pharynx, causing extreme difficulty of inspira- 
tion, which had a peculiar crowing character; he had likewise 
a great desire for water, and complained much of thirst. No 
sooner, however, was this fluid brought into his presence than 
it was obliged to be withdrawn; the sight of it caused an 
alarming increase of pain about the larynx, with a horrible 
feeling of suffocation; but with the removal of the water the 
symptoms became ameliorated. From so many hydrophobic 
symptoms being present, I was apprehensive he might have 
been bitten by a dog, so questioned him upon this subject 
very closely; but to all my interrogations he shook his head 
negatively. During the intervals of ease his pulse was full 
and soft, and averaged eighty beats in a minute; his tongue 
was clean, the bowels were regular, and the skin of the natu- 
ral temperature. Aware that there was a predisposition to 
spinal disease, I examined the back, and found about the 
lower f)art of the cervical region tenderness on pressure, and 
I observed that this pressure invariably produced an exacer- 
bation in all the symptoms, and of this I fully satisfied myself, 
and my patient likewise, by repeating the pressure three or 
four times. A blister was applied over this spot; it rose well, 
and he soon became able to swallow. Doses of opium were 
given by the mouth, and an opium injec^tion was administered 
per rectum. I should have stated that from the commence- 
ment of the attack up to the present period, he has experi- 
enced a great difliculty in passing his urine, but none in void- 
ing his fjuces. 

5. Much improved in every respect; but when his head was 
raised, the sf)asm was speedily reproduced. He had a con- 
stant smacking of his lips, and frequent twitches of his legs 
and feet; the right arm partially paralysed; no headache; no 
confusion of intellect. 

7. 8till improving; s[iasms had entirely disap[)cared; he 
could swallow Huids with the greatest ease; tongue clean; 
bowels well opened; secretions healthy; he can now be raised 
without sudering; the blister discharges freely. The dorsal 
region was lubbed with an embrocation, containing croton 
oil, tartar emetic, &c., and quinine was given during the day, 
with henbane at night. From this period he gradually pro- 
gressed, and at the end of the month was thought sufliciently 
improved to resume his avocation. One day, however, pre- 
vious to his intended departure, he had a recurrence of the 
dyspnoea, but in a much less degree than before. This was 



Enlarged Patellar Bursa. 



229 



immediately treated by the application of leeches to the cer- 
vical region, followed' by a blister, when all the symptoms 
soon vanished. He has two issues, one on each side of the 
cervical vertebrEe, which discharge freely, and he may now 
be considered convalescent. — London Lancet. 



Operation for enlarged Patellar Bursa. — Dr. Hargrave, of 
Dublin, performed the following operation on a healthy house- 
maid, twenty-one years of age, admitted into the city of Dub- 
lin Hospital, with enlarged patellar bursa. 

June Sth, 1S41. — "An incision to the extent of one-eighth 
of an inch, was made along the outer margin of the tumour; 
then a very small bistoury was introduced obliquely into the 
cyst, at such a distance from the superficial cutaneous incis- 
ion as prevented the escape of the fluid. 

"The sac was then cut in several places, chiefly on the 
anterior surface, and the instrument withdrawn, all the fluid 
having been evacuated. 

"A small compress was then applied, and several strips of 
adhesive plaster, and a roller which extended from the toes 
to the knee. 

"A splint was also applied, which extended from the mid- 
dle of the back part of the thigh to the same point of the 
leg. 

"10th. Dressings were removed; considerable diminution 
in size of swelling. 

, "Strips of adhesive plaster were again applied nearly in 
the same way as that recommended by Baynton. — No con- 
stitutional disturbance. 

"14th. Strips quite loose. A strong evidence of subsi- 
dence of swelling. 

"17th. Natural appearances of the joint nearly restored. 

"Discharged at her own request, but strictly cautioned 
against returning to her usual employment for some time. 

"If the incision, or rather punctures into the sac,'' Dr. 
Hargrave says, "be made with care, the internal surface of 
the cyst then cautiously scored after it, the fluid evacuated 
by firm pressure, so as to prevent the ingress of air into the 
cavity, no danger need be apprehended of unpleasant eflfects 
succeeding to this measure." "The only instances, he adds, 
"in which the subcutaneous incision might fail, are those 
where the sac is much thickened, its interior loculated, and 



230 



New Antidote for Corrosive Sublimate. 



the cells filled with a thick gelatiniform substance: still in 
such instances, it is a means which should be kept in view." 
Am. Jour. Med. Set. from Dublin Med. Press, Oct. 26, 1842. 



Proto-sulphuret of Iron, a new Antidote for Corrosive 
fiublimnte. — By Miamie. — It results from my experiments, 
that the protosulphuret of iron, a totally inert article, in- 
stantly decomposes corrosive sublimate, giving rise to two 
inoffensive com[)ounds — proto-chloride of iron and deutosul- 
phuret of mercury. This invaluable property leads me to 
announce the protosulphuret of iron, in the form of hydrate, 
as affording by far the best antidote for this poison. 

At some future time I will publish the details of my chem- 
ical researches, as well as the results of the physiological 
experiments which I propose to institute on this subject. In 
the mean time, I advance a chemico-physiological proof in 
tavor of the efficacy of this antidote which appears to possess 
real value. 

Whenever a few centigrammes of corrosive sublimate is 
placed in the mouth, it immediately produces its characteris- 
tic insupportable metallic taste. It is then sufficient to wash 
out the mouth with the hydrated protosulphuret of iron, in 
the state of a thin pulp, a condition in which it should al- 
ways be used, to cause all the metallic taste to disappear as 
if by enchantment. This fact needs no commentary. It 
speaks for itself, without need of any explanation. 

This antidote is not restricted in its effects to the soluble 
compounds of mercury — it serves also to destroy the injuri- 
ous action of many other metallic salts, and particularly those 
of copper and lead. 

To prepare the protosulphuret of iron, any quantity of 
pure protosulphate of iron is to be dissolved in at least twen- 
ty-four times its weight of distilled water, which has been 
boiled to drive off any atmospheric air; this solution is to 
be precipitated by a sufficient quantity of protosulphuret 
of sodium, likewise dissolved in boiled distilled water. The 
protosulpliuret of iron thus formed is to be washed 
with pure water, and preserved for use in a closely stopped 
bottle, which is to be completely filled with distilled wa- 
ter. 

Although the protosulphuret of iron may be made in a few 
moments, it is nevertheless proper that it should be kept 



Cure of Crooked Nose— Itch at Berlin. 231 



ready prepared, to avoid the loss of any precious moments in 
a case of poisoning. 

The direction to preserve this sulphinet from contact of 
the air should be veiy strictly followed, as this compound has 
a strong tendency to pass to the slate of sulphate. — Arncrican 
Jour, of Pharm., from Journal de Pharm. and Chini. 



Cure of Crooked Nose by Subcutaneous Division of the 
Cartilages. — By Prof. Dieffe.mjach. — [Dr. Diefl'enbach re- 
marks that the wrynose is eitlier a natural deformity, or 
is caused by accident. He has operated in two cases with 
complete success: in one ihe deformity was congenital, and 
in the other it was caused by a fall. He thus describes the 
operation:] 

With a small curved bistoury 1 made a puncture by the 
side of the bridge of the nose, at the point of union between 
the cartilage and the bone, the bistoury was then carried un- 
der the skin, so as to separate the cartilage of the side and 
bridge of the nose from the bone. By a second puncture, 
on the other side, the middle partition of the nose and the 
cartilage of that side were divided. 

The nostrils were then stufled with lint, and the nose re- 
tained in its proper position with strips of plaster. The 
parts healed quickly, without inflammation or suppuration. 

N. Y. Lancet from Gaz. Med. 



Mode of Treating Itch at Berlin. — By Dr. Halck. — 'l"hc 
treatment of itch has lately been made the subject of exten- 
sive experimental observation in the Berlin hospitals, and it 
is satisfactory to learn that a slight modification of what is 
termed the English method, has been found in every respect 
superior to any other that was adopted, accomplishing as it 
does all the desirable objects of curing the disease quickly, 
certainly, and economically. 

The remedy employed was the sulphur and soap liniment 
of the Prussian IMilitary Pharmacopcria, composed of one part 
of Qowers of sulphur, and two parts of soap mixed with suffi- 
cient hot water to make them into a soft ointment. The 
patients, after a warm bath of soap and water had been ap- 
plied, were placed undressed in a chamber, kept constantly 



332 



Itch at Berlin. 



at a temperature of 95° F., and well rubbed with the oint- 
ment over all the parts where the eruption had appeared, 
three times a day, and then made to sweat profusely by put- 
ting them in warm beds. This system was continued for 
three days and nights; on the morning of the fourth each pa- 
tient had a warm bath, and then if not cured, was provided 
with clean bed and body-lincn, and put in a ward of ordina- 
ry temperature, while the suspicious parts were still rubbed 
with tlie ointment, and a warm bath taken every other day. 
In general, no external medicines are given; but the diet al- 
lowed was reduced to a fourth portion, and water only given 
to drink. 

In this manner, but with one short interval, 1981 were 
treated and cured between ScpLcmber, 1839, and February, 
1840, making the total number of days of treatment 15,890, 
which gives on an average eight days and a small fraction 
for the cure of each of patient, and for the expense of each 
about two dollars. The exact result was, that — in three 
days there were cured 42, in four days 161, in five days 
333, in six days 37G, in seven days 207, and in more than 
seven days 859. 

•The treatment of these last was prolonged by many cir- 
cumstances which can hardly cast discredit on the remedies. 
In many among them llic ilcli was soon cured, but they re- 
mained under treatment for tlic ulcers which come on from 
long neglect of it, or were kept in the hospital till there was 
no chance of the ulcers communicating the disease. Others 
among them after being cured of the skin disease had to be 
treated for other aH'octions, such as ophthalmia, fever, &c.; 
and others again had their cure delayed by an obstinate refu- 
sal to adopt all accessory treatment. And in addition to 
these causes giving rise to an apparent increase of the length 
of time necessary for tiie cure of the disease, tliere were some 
others dependent on tlie management of the hospitals, and 
other circumstances quite foreign to the treatment adopted, 
but which, had they not existed, would have permitted the 
average number of days of treatment to have been stated 
much lower. 

In the whole fifteen months tlierc occurred only eight cases 
of relai)se, less that is than half i)er cent, of the cases treat- 
ed; and among these there was, in many, good reason to sus- 
pect a fresh infection. The other cases in which there ap- 
peared to be a relapse were in fact only examples of eczema 
resulting from the stimulus of the skin by the sulphur. In 
no case did the treatment of the skin give rise to any general 



Sleep of Animals and Man, 



233 



disorder, or to the inflammations and congestions which 
some have described as resulting from it. — A'. Y. Lan., irom 
British and Foreign Medical Review. 



Sleep of Animals and Man. — Most animals sleep more 
than man; some indeed for months— as the hibernating tribes 
of bats, dormice, marmots and bears. Cats and dogs would 
seem to have the faculty at will, as have some idiots and per- 
sons of a low order of intellect. The ideas or impressions 
upon their minds are so feeble or so few, or are made at such 
long intervals that succession is lost for want of continuity; 
hence the organ retains imperfectly, and but for an instant, 
the image which the external senses have presented to it; 
weariness supervenes, unconsciousness follows, and lastly, 
sleep, as a necessary consequence of inanition, is induced. 
It is observed, however, that monkeys do not sleep as much 
as other animals. Whence is this apparent deviation from 
the ordinary law of nature affecting animals? Is a monkey 
a reasoning animal? Observe a dog chained: he twists his 
chain, shortens it, and cuts himself off from his platter. 
Does he seek to untwist it, to restore the links to their wont- 
ed extension? No; he continues tugging and howling till some 
friendly hand frees him from his toils, and restores him to his 
former range. But how is it with the monkey under similar 
difficulties? Why, he deliberately untwists the chain w-hich 
he cannot sunder, and hence evinces something like reason. 
Is the sleeplessness of monkeys then a proof of reason? 
We think so. But infants are frequently sleepless? Yes; 
but never in a stale of health. Restlessness in them is al- 
ways an indication of hunger, or a symptom of disease. The 
absence of sleep cannot be long sustained. Damiens slept 
on the rack; Luke in his iron crown; and a battalion of in- 
fantry have been known to slumber during a march! Mule- 
teers frequently sleep on their mules, post-boys on their hor- 
ses, and seamen "on the high and giddy mast," "Massa 
call you," said a negro to his comrade who had fallen asleep 
near him; "Sleep has no massa," replied the wearied boy; 
and he was right. We may bear the privation of fire, food, 
and even drink, longer than we can the want of sleep. — Dr. 
Sinn's Anatomy of Sleep, 



1 



234 Nasal Enlargement Successfully Treated. 

Case of Nasal Enlargement successfully treated. — By Dr. 
Chas. Clay. — This was a case of peculiar enlargement of the 
nose, in a young lady, unaccompanied with pain or any othfi: 
inconvenience than the size. Besides constitutional treat- 
ment, Dr. Clay made pressure on the organ, by means of a 
mould made of plaster of Paris, which was useful not only 
by pressing uniformly, but also by its mere weight. The 
mould was secured to the head by different tapes, which were 
applied so as to increase the pressure. In a week the mould 
was found too large, and a second one was made; a third, 
fourth, and fifth were obliged to be made, as the nose dimin- 
ished in size, till it regained its natural dimensions. 

London Lancet. 



THE WESTERN JOURNAL. 



Vol. VIL— No. III. 



LOUISVILLE, MARCH 1, 1843, 



TRAVELLING EDITOEIALS. 

This phrase admits of no less than three applications. It may 
mean editorials for the benefit of travellers; editorials of such excel- 
lence and interest, that they will travel far and M^ide among the pro- 
fession; or editorials written while travelling. It is in the last sense 
that we use the expression. Of the course and limits of th(- jour- 
neyings on which we have entered, an intimation was given in our 
January number. Of the materiel which we may work up into our 
monthly communications, we cannot speak so definitely; inasmuch 
as we know not what may offer, and do not intend to be rigidly pro- 
fessional. That would be to come with "malice prepense" into con- 
flict with the tastes and habits of our brethren, many of whom, with 
ourselves, know a good deal out of the profession, however little 
they and we may know in it. When Lord Brougham was made 
Chancellor of England, a London wag exclaimed, what a pity it is, 
that his lordship does not know something of the duties of his high 
office, for he would then be a man of universal learning. Disclaim- 
ing all personal application of this sarcasm, we shall proceed to 



236 



Travelling Editorials. 



state, in this first letter, the object which is carrying us to the shores 
of the Gulf. 

/ Diseases of the West. 

I More than twenty years ago we announced the design of publish- 
/ing a work on this subject. Of the causes which have delayed its 
preparation, we shall not speak in detail, and will mention one 
only. Reflection soon convinced us, that the undertaking was of 
greater magnitude and difficulty than it first appeared, and could 
not, indeed, be accomplished without extensive and patient personal 
observation, particularly in the the north and the south, that the 
feathering out of our endemics in those opposite directions might be 
distinctly ascertained. But excursions for that purpose were imprac- 
ticable, till the last summer, when, in visiting the shores of the Lakes, 
wc commenced the series of medical travels which have now been 
resumed. In their prosecution, it is our object, 1st. to acquire a 
knowledge of the modifications of our climate, from the Lakes to 
the Gulf, with their influence on the constitutions of the people." 
2d. To note the various geological and topographical conditions, which 
may be supposed, directly or indirectly, to occasion or prevent dis- 
eases. 3d. To observe the diet, drinks, occupations, and manners 
and customs of the inhabitants, as predisposing to, producing, or 
preventing diseases. 4th. To obtain from medical gentlemen, in all 
parts of the country, such information concerning the diseases preva- 
lent in their respective localities, as can be drawn from them by per- 
sonal interviews. 5th. To collect facts for a comparative estimate 
of the physiology and pathology of the Europo-American, the Indian 
and the Negro. 

Our field of observation extends from Michigan to Florida, and 
from the western slopes of the Allegheny mountains, to Missouri, 
Arkansas, and Iowa. 

Such is the enterprizc on which we have entered at an advanced 
period of life, though with some of the activity and feeling which 
belong to earlier years. Should we not live, or otherwise fail, to 
achieve it, we have the satisfaction to believe that our researches 
may still be of some benefit to the profession, inasmuch as we can 
scarcely fail to record many valuable facts, which might otherwise 
be lost, and which by some abler hands may be presented to the 
public. 



Travelling Editorials. 



237 



In addressing these paragraphs to our readers, and all other medi- 
cal gentlemen within the extended region we have designated, we are 
actuated by an earnest desire to secure their co-operation. Without 
it, a failure is inevitable; Avith it, some degree of success may be 
regarded as almost certain. Therefore we respectfully solicit their 
co operation. We shall devote the months of March and April to 
Florida, South-Alabama, and the south-east of Mississippi; May to 
the Delta of the Mississippi; and June to the upper parts of Louis- 
iana, the western portion of Mississippi, and the eastern part of 
Arkansas; and we take this method to request such of our readers as 
reside in those States, to prepare for us, in writing, such transcripts 
of their experience as may be fit materials for our projected work. 
We would, moreover, extend this request to all who practise medi- 
cine in the various States west of the AUeghenies, in the hope, that 
they will at once perceive the necessity of their co-operation, and 
that they will forward to us, at no distant time, the facts which are^ 
requisite to a full history of our most important diseases. ^ 

Bed and Banks <tf the Mississippi. 

If it had a rocky bed and banks, well defined, and unchangeable, 
the Mississippi would be tlie most magnificent of rivers. As it is, 
neither beauty nor grandeur can be ascribed to the "Father of Wa- 
ters." His great attribute is power, but in its exercise he is so often 
obstructed and foiled as to detract greatly from his dignity. At the 
very moment of writing this sentence, the afternoon sun shines upon 
us through the stern windows of the Queen of the West, sho^ving 
that she runs nearly north-east instead of south. Thus it is that the 
tide of rolling waters is deflected from its course, and almost turned 
back, by the banks of mud and sand which itself has brought down 
and deposited. Struggling to reach the Ocean, the true father of 
rivers, it is compelled to fight its way, to turn aside, to abandon its 
old channels and excavate new ones. For a short distance the 
waters may flow between parallel and equally elevated banks, but 
they soon spread out on one side, or divide into difl'erent channels, 
which, crc long, they are compelled by new accumulations of sand 
and sunken trees to abandon. Seen from the surface of the stream, 
the higher banks present a perpendicular and ragged front, from 
which masses are perpetually falling into the stream, to pollute its 
waters for a time, and then desert them for a new location. The 



V 



23S 



Tra vel/i ng Ed itorials. 



horizontal and waved stratification of these banks, mark them as 
deposites from the river itself, consisting of varying proportions of 
sand and clay, with enough of the carbonate of lime to render many 
specimens slightly effervescent. A medium height of water is that 
■which does greatest mischief to the banks; and its abrading force is 
greatly increased by the waves raised by a southerly wind, and by 
the wheels of the numerous and powerful steamers, which, in ascend- 
ing, overcome, in descending, outstrip the current. As the latter 
must long continue to be an increasing cause, the work of destruc- 
tion is not likely to abate. Opposed to the perpendicular and crum- 
bling banks, are low and shapeless beaches, which in high water are 
buried up, but in low, present extensive deposites of drift on their 
slopes, while their flatter surfaces are covered with dense groves of 
young cotton trees. Now and then three, very often two ranks of 
this kind, having different ages, may be seen from the river, the 
youngest in front, the oldest in the back ground. This tree, the 
Populus ang%ilata of the botanists, gives character to the Sylva 
MississippiENsis, and, if not th^offspring, is at least the adopted 
child of the waters, which deposite the soil in which it attains a 
magnitude unknown elsewhere; while its down enveloped seeds, in 
countless millions, are transported by the current to every new plan- 
tation, where they speedily germinate. The trunk of this tree makes 
excellent fuel for steam-boats, and thus will the Mississippi forever 
create the means by which man will stem its mad and mighty cur- 
rent. If the trees upon its banks were to perish, or the cotton wood 
become incombustible, the effect would be felt throughout the entire 
west. 

Tertiary Formations. 
Such of our up country readers, as have trodden from their infancy 
upon rocks of the secondary class, would do well, should they de- 
scend the river, to keep a good look out for the Chickasaw bluffs of 
Randolph and Memphis. Vicksburg, Grand-Gulf, and Natchez, pre- 
sent fine sectional views of the tertiary formations which stretch so 
extensively through West-Tennessee and the middle portions of Mis- 
sissippi and Alabama. 

Steamboat Bars. 

Now, that ardent spirits are no more seen on the dinner tables of 
our steamers, and the number of passengers, who desire or dare to 



Travelling Edilorials. 



•239 



frequent the bars, is greatly reduced, it would seem to be natural, and 
not difficult, to suppress them entirely. The chief motive for retaining 
them is destroyed, when they yield but little profit; and, therefore, 
the owners of boats might be expected not to resist their abolition. 
But under what influence can this important reform be brought about? 
We answer, that of the friends of temperance, exerted on the gene- 
ral government. After having legislated on the registration and in- 
spection of steamboats, even to a prescription for tiller chains, it 
would be no unwarrantable exercise of power, to suppress the sale 
of intoxicating drinks, both to passengers and operatives. The prin- 
ciple on which Congress might place this interposition, is the same 
as that on which they have directed chains for ropes — the safety of 
passengers. No observing man can believe but that many of the 
disasters which have happened to our steamboats were the effect of 
intemperance, particularly indulged in at night; and that, with its 
suppression, the number of accidents would be signally abated. We 
cannot but ardently desire to see the friends of temperance move in 
this matter. 

' Ivdia Rubber Life- Preservers. 

On our present voyage down the Ohio and Mississippi, not less 
than before, we have marvelled to see so few of these valuable arti- 
cles. Hundreds who now travel on steamers without them, would, 
if they had never been invented, deplore the Avant which they now 
neglect to supply. With a good life preserver around her chest, 
even the most helpless and timid woman, would be safe for several 
hours unless the water might chance to be as, it now is, but two or 
three degrees above the freezing point; and still but few ladies are 
provided with them, and still fewer gentlemen, although none of the 
former and not many of the latter know how to swim. By the way, 
it is a serious and absurd defect, in the physical education of our 
daughters, that they are not taught to swim; as it is a valuable exer- 
ci.se in early life, and a source of confidence and security even to old 
age. In past times, when our women remained at home, because 
tliey could not travel, the latter consideration was of less moment 
than at present, when so many perform long voyages, at every mo- 
ment exposed to casualties which might drown them, merely be- 
cau-se a day had not been devoted to their instruction in the art of 
swimming. 



240 



Travelling Editorials. 



Steamboat Explosions. 
passengers who are exposed to these accidents ought to know, 
that the steam which spreads through the cabin, when explosions 
occur, will not scald those parts of the' body which are covered even 
thinly. Thus, those, who are in their berths when such an accident 
happens, should lie still, and cover up their heads, instead of rising, 
as has so often happened; and those who are up, might protect them- 
selves by covering their hands and face with an apron, the skirts of a 
coat, or even a silk handkerchief. Reaching the skin through such a 
fabric, steam, which would otherwise blister, will scarcely redden it. 
A further precaution, not unworthy of notice, is to suspend or hold 
the breath, at the moment of 'becoming enveloped in the steam, by 
which its introduction into the larynx and lungs is prevented. 
Winter Temperature of the Mississippi. 
From the mouth of the Ohio to New Orleans, the distance is one 
thousand fifty-nine miles — the distance on the meridian 3 degrees, 
rejecting small fractions. Thus in passing through a degree of lati- 
tude, the river flows three hundred and fifty-three miles. Its temper- 
ature at the junction between it and the Ohio, we found to be 34°, 
which rose at a constant rate to New Orleans, where wc find it 42°; 
giving an increment of two degrees and two thirds of surface tem- 
perature, for one degree of latitude, and for every three hundred and 
fifty-three miles of current. 

Climate of New Orleans. 
The very night of our arrival afforded conclusive evidence that 
great and sudden changes of temperature occur in the delta of the 
Mississippi. On the 14th of February, when below Baton Rouge, the 
heat oftheair, athalf pastil A". M.,was71°. Rain with thunder and 
lightning ensued, accompanied by westerly winds, and in two hours 
the thermometer sunk 19°. Before sun-rise the next morning, at the 
wharf, it was at 28°, making a fall of 43° in twenty hours. A 
more extreme change seldom occurs in any latitude. The next 
morning it was at 32°. This morning at 34°, with a copious white 
frost. The liability of this climate to such great depressions of tem- 
perature, so late as the middle of February, should admonish those 
who seek for relief from pulmonary diseases, by a voyage to the 
south, to look out for disappointment, if they start in winter, or stop 
here. D. 
New Oeleans, February 17. 1843. 




THE 



WESTERN JOURNAL 

0 F 

MEDICINE AND SURGERY. 



APRIL, 1S43. 



Art. L — Post-mortem Researches. By Bennet Dowler, M. 
D., of New Orleans. 

[The reader will excuse the references to dissections not 
yet published. A want of lime to copy from my MSS. in 
folio volumes must be my apology for using the scissors, in- 
stead of the pen, in collecting the detached portions from 
which I have patched this article into its present form. 
For a part of the dissection, on which the paper is founded, I 
am under great obligations for assistance, to the following 
gentlemen: Dr. Wederstrandt, R^^ident Physician of the 
Charily Hospital; Messrs. Saunders and Bates, resident stu- 
dents of the same; Drs. Osborne, Young, Luzenberg, and 
Nicholson.] 

When in the course of medical inquiry, we meet with dog- 
matism on the one hand, skepticism on the other, and uncer- 
1 



I 

242 Dowler on Post-mortem Researches. 



tainty every where, we cannot do better than to appeal at 
once to tlie decisions of post-mortem anatomy, which, though 
they may fail in settling some points in dispute, will deceive 
us in none, and satisfy us in many. One author asserts, that 
there are one hundred and fifty fevers; another, that there is 
but one. What Goethe says of the satirical poet, is applica- 
ble to the medical controversialist, who surrounds himself 
■with a "dazzling fence of logic," and is eager for the con- 
flict — "When I have called the bad, bad, how much is gained 
by that? The man who would work aright must not deal in 
censure, must not trouble himself about what is bad, but 
show and do what is good." 

The book of Morbid Anatomy, though written by Nature, 
is a book of knowledge to those only who read patiently, and 
interpret its language truly. Pride and self-sufficiency, alonei 
will deride and decry this modest, safe, though laborious 
mode of investigation. It was a homely but just saying of 
one of the reformers, that every man carried a Pope in his 
belly. There is, however, one panacea for the cure of medi- 
cal infallibility, which is this: let a practitioner, of this class, 
carefully dissect fifty or more persons treated by iiimself, or 
by another; let him estimate the blunders he has commit- 
ted — blunders, that an accurate knowledge and a careful 
examination of the land-marks of disease, might have pre- 
vented! and, though his stock of pathological fiction may be 
diminished by this process, he will lose nothing valuable- 
Romance will be re-placed by reality. The piratical maxim, 
"that dead men tell no tales," is erroneous; they are the best 
witnesses. 

To say that morbid anatomy throws no light upon medical 
treatment, is an admission flattering to empiricism, unjust to 
our science, fatal to investigation, opposed to truth, and at 
best, an indirect attempt to excuse professional indolence. 
Some may think that the following quotation from an able 
writer is too sanguine in its anticipations; but, what good ran 
we derive from despair? "The time cannot be far olF, when 
the term fever must be entirely discarded from our books, 



Dowler on Post-moriem Researches. 



243 



and diseases named according to the tissues which they 
implicate. Then, and not till then, can it be expected that 
the laws of deranged action will be properly interpreted, or 
fully comprehended. All diseases, I feel confident, will ulti- 
mately be found to have a local origin and habitation. The 
artificial nosology of Sauvages, of Hoffmann, Cullen, &c., has 
had its day." (Prof. Gross' Path. Anat. vol. i, p. 30.) 

It is, perhaps, true, that pathological anatomy is in advance 
of therapeutics. Both are in a state of infancy. The sooner 
we learn the true position of the enemy, the better. 

The sentiment which Boswell makes Jolinson utter con- 
cerning his opinions, applies but too often to the physician-. 
♦'I don't like to have any of my opinions attacked. I have 
made up my faggot, and if you draw out one, you weaken 
the whole bundle." 

Numerical aggregations, numerical analyses, numerical 
AVERAGES, promise results, which, though less certain than 
mathematics, less poetical than speculation, will, with every 
succeeding generation, approach nearer to perfection. The 
amount of labor by this method, for a single individual, would 
be absolutely appalling to the most ardent imagination; "but 
many hands, make light work." The book of symptoms, the 
book treatment, the book of morbid anatomy, remain to be 
written upon this statistical system. To count correctly, to 
overlook nothing, lo observe philosophically, is a heavy under- 
taking, more especially as the chaff and the wheat, the ore 
and the dross, must often of neccssilj' be collected at the 
same time: the laborer cannot always pre-determine which 
are the essential pathological facts, anterior to results, since 
these are the objects of his pursuit, and are not, as yet, sup- 
posed to be fully appreciated and known. A few facts, how- 
ever correct, cannot be relied on for establishing general 
results, or principles. Analysis is the ordeal which tries his 
materials, and consumes the uselesss. Even if he discover 
nothing new, he confirms what was discovered before, and 
shows its proportional frequency, order, and connexion with 



244 



Dowler on Post-mortem Researches. 



other events. The numeric method, is something better than 

the EASY METHOD, CONJECTURE. 

A more extraordinary statement than that of Louis 
was scarcely ever made, by a cultivator of medicine whose 
experience had been very extensive: "he says at the close of 
his labors, when he submitted all his facts to the unerring 
test of arithmetical analysis, that in every instance ivere the 
a-priori conclusions which he had formed from the recollection 
of his own facts found to be erroneous" The import of this 
statement seems to be, that all systems of medicine, except 
the ARITHMETICAL, are more likely to prove false than true, 
upon analytic examination. 

In order to test this apparently absurd, and paradoxical 
principle, I spent considerable time, for several successive 
days, in examining the tongue alone, in persons in all stages 
of yellow fever, writing down the appearances at the bed 
side, in the charity hospital, during the epidemic of the year 
1841; and, though I iiad been extensively engaged in prac- 
tice during several epidemics, and had written many cases, 
which I have not to this day analysed, yet I found my pre- 
vious opinion had been erroneous, so far as the cases above 
mentioned afford a rule by which to judge. I had supposed, 
from memory, that the tongue of most persons aflected 
with this fever, had some well marked morbid appear- 
ances. But, though some were found to be red, some white, 
some pointed, some tumid, some dry, &c.; yet, the majority 
were natural. I am far from thinking that memory, when 
tried by the mere test of arithmetical medicine, will prove 
generally thus treacherous, or that the cases above men- 
tioned are sufficient to prove, in most cases of yellow fever, 
that the tongue is healthy. 

Number, as an element in working out results, is a safe 
guide, only so far as its facts are accurate, pertinent, and 
essential. In morbid anatomy, which is, in connexion with 
symptoms, the foundation of correct treatment, these are all 
important, otherwise, we must fall into errors the most fatal 



Dowler on Post-mortem Researches. 



245 



under the imposing array of statistics, and medical jiathe- 
MATics. Aggregatioxs may be true, and yet of no value. 

The object of this paper is, therefore, to notice some of 
the difficulties, errors, and modifyiiig circumstances, incidental 
to a just appreciation of morbid appearances, some of which 
have been often overlooked or misapplied. The numeric is 
eminently a false method, when its facts are inaccurately 
stated. 

The sooner post-mortem examinations are made, the better. 
This matter we will illustrate as we proceed. The French 
writers, who excel in pathological anatomy, have not, cer- 
tainly, overlooked the great changes that take place in the 
body within thirty-six hours after death. If they have erred 
it is in overcharging the picture. But in this, as in some 
other cases, their knowledge is in advance of their prac- 
tice. Andral says, that, "in almost every body, opened 
at about thirty-six hours after death, reddish eflusions 
are found in the cavities, red ecchymosed spots in the great 
cul-de-sac of the stomach," &c. (Path. Anat., vol. i, p. 49.) 
And yet, strange to say, this is about the average period, 
for post-mortem examinations, among the most eminent 
French pathologists; a fact which throws no little obscurity 
and doubt, over the results of their numerous observations. 
Open almost any of their works, and it will be seen, that 
their autopsies have been delayed from twenty-four to forty- 
eight hours after death. Louis, in his work on consumption, 
records fifty-one cases in which the period of the dissection 
is mentioned, making an aggregate of fifteen hundred and 
five hours, affording an average to each case of more than 
thirty hours; his other works, will, I suppose, give about the 
same average, except his book on the yellow fever of Gibral- 
tar, which gives fifteen. 

If I am not much mistaken, the celebrated Broussais never 
mentions the period of his post-mortem examinations at all. 
In Cook's Morgngni, the same omission is almost constant. 
Bertin's work on the heart, approved by the Academy of 



246 



Dowler on Post-mortem Researches. 



Medicine, has thirty-three dissections, the average to each 
being nearly twenty-nine hours after death. 

Rilliet and Barthez, on the pneumonia of children at 
Paris, record a number of examinations, none sooner than 
twenty-eight hours, and some as late as forty-four hours. In 
Billard's interesting work on the diseases of children, the pe-. 
riod of the numerous dissections is not mentioned with any 
precision, except in two or three cases. He often says the 
dissection was performed next day. Now, this may mean 
seven or eight hours, or it may mean nearly two days. A 
person dying at 10 o'clock, A. M., may be examined the 
next day at 5 or 6 o'clock, P. M., forty or forty-one hours 
after death. Though fractional parts of an hour may be of 
no importance, even in hot weather, yet, when the dissection 
is delayed two days, as is often the case with these and other 
authors, many conflicting elements conspire to efface appear- 
ances that existed at death, or to create others, simulating 
anatomical characters of diseases which did not exist. 

' Out of one hundred and fourteen yellow fever dissections, 
not to mention others, a large number were made, or at 
least begun, from five to ten minutes after breathing ceased, 
before cadaveric injection, permeation, congestion, and exu- 
dation, had time to cause any alteration; hence, it may be 
inferred that the exact condition of the organs is truly re- 
flected. 

I have caused the body to be placed on its right side, for 
example, immediately after death, both in the night, when 
the air was cool, and in the day, when it was warm, and in 
from three to six hours, have observed that the upper or left 
side was comparatively bloodless, while the lower was load- 
ed with blood externally and internally; the intestines being 
ifinely injected, and much reddened, in such dependent parts 
as were most favorable for the influence of gravitation. 
(Dissection XLIV.) But dead bodies differ very much 
from each other in their susceptibilities to cadaveric infiltra- 
tion. Death, in the common acceptation, may, and often 
does, lake place hours before the body dies in a physiologi- 



Dowler on Post-mortem Researches. 



247 



cal sense. Volition, thought, sensation, respiration, and the 
heart's action have ceased, and for all the purposes of existence, 
life is no more; but it does not hence follow, that all the 
vital actions are extinct; both animal and organic life may 
exist in many cases. - As a proof of this, muscular contraction 
and capillary circulation, which these dissections fully estab- 
lish, might be mentioned. 

As MUSCULAR CONTRACTION, after apparent death, is not 
known to exert a modifying agency over the morbid appear- 
ances, it is referred to here, merely as confirming the doc- 
trine of capillary circulation, as surviving that of the heart 
and large arteries — a doctrine, which if true, renders tardy 
dissection a most fallacious guide in judging of venous con- 
gestions, vascular turgescence, organic reddenings, blan- 
chings, &c. 

The precise boundary line between life and death, is dubi- 
ous and undefined, and the dissector cannot commit a greater 
blunder than to wait for the work of putrefaction, or even 
post-mortem infillralion, gravitation, &c. 

According to my observations, muscular contractions, after 
death, are more common in ihe yellow fever subject than in 
any other class of fever victims. 

A slight scratch with the back of the knife across the 
course of the muscular fibres, in any part of the body, causes 
the muscles to contract, and to swell into firm ridges exactly 
at the line of mechanical irritation. The summits of these 
elevations are sometimes an inch above the surrounding level, 
with bases of two or three inches in diameter, the muscu- 
lar fibres assuming zigzag, wavy lines, until they relax into 
repose again. 

Observe the arm as it lies extended upon the table, su[)ple 
and relaxed — we strike it with a horn, a cane, or metallic 
rod, a conductor or non-conductor of electricity, either on 
the skin or on the naked muscle — contraction takes place in- 
stantly, or sometimes slowly: for example, we strike the 
biceps muscle, about its middle — the arm is bent, the hand, 
perhaps, strikes a violent slap against the face, or rises more 



218 



Dowler on Post-mortem Researches. 



slowly with an uniform motion pointing to the zenith, and 
then gradually fails back from the perpendicular to the hori- 
zontal position. This operation may be repeated for several 
hours, in some cases just so long as the muscular contractil- 
ity remains unimpaired. In some subjects, this property 
does not exist, and it varies in different parts of the same 
subject; the masseter muscles lock the jaws firmly together, 
in some cases before death, oftener just after; the recti and 
other abdominal muscles, in a few instances, become rigid in 
like manner, while the fore arm bounces from the table after 
every blow given even by the fist of the operator. When 
the rigidity of the entire musclar system exists, this proper- 
ty is lost; but where the entire body is supple, it does not 
follow that the power of post-mortem contraction is always 
present. It exists in the fibres of the heart, but is seldom 
sufficient to move the whole organ. 

Examples might be multiplied were it desirable: the fol 
lowing are supposed sufficient for the present occasion: 

E. M : (Dissection XCII.) A stroke on the arm between 

the shoulder and elbow, caused the fore arm to rise from the 
table, and after continuing perpendicular about a quarter of 
a minute, it slowly fell back to tlie horizontal position. Du- 
ring the period that the arm continued elevated, the muscles 
where the blow had been given were contracted into a ridge, 
which, gradually sinking, the arm fell down to the level 
again. These experiments were often repeated with the 
same results; other muscles, in diflerent parts of the body, 
jerked or contracted when scratched or irritated. 

0. S : (Dissoctioa XCIV.) This subject when struck, 

as in the last case, contracted his arm strongly, sometimes 
holding it up a minute after the stroke. The experiment 
y^as repeated for several hours. 

Not wishing to enter upon the subject of the capillary cir- 
culation, only so far as it may exert a modifying influence 
over the post-mortem appearances, I may however be permit- 
ted to say the following facts prove that the direct action of the 
heart, and its indirect, or suction power, joined to the sue- 



Dowler on Post mortem Researches. 249 

tion produced by respiration, are not necessary to the rapid 
motion of the venous blood. 

It has been observed by dissectors, that, in the dead body 
the left side of the heart and all the great arteries are general- 
ly found empty. Now of all conceivable facts, this is pre- 
cisely the fact which ought not to happen, upon the theories 
which are usually brought forward to explain the capillary 
circulation. We might, on the contrary, expect to find the 
left side of the heart and arteries distended, the veins empty. 
It is erroneous to say that the heart and arteries possess a 
contractile power, which, after death, expels the blood. We 
have but to look into the body to see the arteries, not col- 
lapsed but hollow, not contracted but large, not gorged with 
blood during the last moments, when the heart is no longer 
able to impel it onward. Considering the emptiness of the 
arteries, it is surprising that they do not contract or collapse 
completely when exposed to the pressure of the atmosphere, 
without counteracting distention from blood within thejf cali- 
bres. Moreover, the circulation of chyle by the lacteals, 
and of lymph by the lymphatics, cannot be accounted for by 
the heart's action, directly or indirectly. 

1 had not proceeded far in the yellow fever dissections, in 
1841, before several cases of rapid and copious haemorrhage 
took place from incisions in the scalp for the purpose of re- 
moving the skull-cap, and from incisions in other parts of 
the body. The quantity of the blood, the force with which 
it was discharged, and the elevated points from which it 
flowed, all indicated a power greater than gravitation as well 
as essentially different in its mode of operation. 

F P , aged nineteen, was, about fifteen min- 
utes after death from yellow fever, placed on an inclined 
plane, the head being the highest part of the body. An in- 
cision, beginning an inch above the eyes, and continuing 
around the head, at the same distance above the ears, dis- 
charged, from the forehead, temples, and other parts, one 
pound and a quarter of blood, in about fifteen minutes: on 



250 Dowler on Post-mortem Researches. 



removing the skull-cap and dura mater, without wounding the 
brain, the same quantity flowed in half an hour, natural in 
color, coagulating as in health. (Dissection XXI.) 

The body of a man aged thirty, two hours after death from 
yellow fever, was placed upon the dissecting table, the head 
being the most elevated part; a circular incision, made an 
inch above the ears, discharged in half an hour from sixteen 
to eighteen ounces of good colored blood, which formed a 
coagulum of good consistence. (Dissection XX.) 

A young man, ten minutes after death from yellow fever, 
was placed on a table, as above; the brain was quickly re- 
moved, and in a few minutes after, about twenty-four ounces 
of blood flowed from the vessels of the head. The blood 
was of a good color and coagulated firmly. (Dissection 
XVIII.) 

L. B , aged twenty-one, immediately after death 

was placed on the dissecting table, the body being very 
warnv and the veins full: the chest was quickly opened. 
Dr. Young, of this city, who assisted in the dissection, 
thought he discovered a slight movement or contraction of the 
heart. The subclavian vein was opened at about the middle 
of its course. From the orifice the blood shot up two or 
three inches, an elevation greater than any part of the body, 
running with such force as to appear like a vital action. From 
three to four pounds of good colored blood, clotting as it 
cooled, were discharged in about half an hour. (Dissection 
LVII.) 

G. J , of Pittsburgh, aged thirty-two, in one hour 

after death, discharged from an orifice in each jugular, made 
by Mr. Saunders, student of medicine, eight pounds of healthy 
blood, according to the estimation of several medical gentle- 
men. At first the blood shot out some distance. In the 
second and third hours after opening the veins, about twenty 
ounces more flowed, before opening any of the cavities. The 
muscles, which were of extraordinary size and beauty, pos- 
sessed contractility for several hours. (Dissection LXVI.) 



Dowler on Post-mortem Researches. 251 



In the case of J B , of L , the post-mor- 
tem blood-letting was nearly as profuse as in the above, (Dis- 
section LXII.) 

J C , aged thirty-four, about five minutes after 

death presented the following evidences of capillary circula- 
tion: 

The veins of the neck and extremities were prominent, 
A vein was opened in the left arm — the blood flowed copi- 
ously, and jetted freely, on moving the muscles. On passing 
a ligature around the right arm, as for ordinary blood-letting, 
the veins became more prominent; one being opened with a 
lancet, the blood shot out as in the living subject to the dis- 
tance perhaps of eighieen inches. The left jugular was 
immediately opened, from which the blood flowed freely, but 
without jetting; and in an instant after, the abdomen and 
chest were exposed, by a rapid dissection. One of the 
branches of the coronary vein of the heart, upon its most 
elevated part, was punctured, and though this twig was not 
larger than several others which were distributed upon the 
hearts' surface, yet, in a few minutes, (ten to fifteen,) it dis- 
charged one pound or more of blood. The omenta, mesen- 
tery and other viscera, had their external veins beautifully 
and equally distended. The hollow veins being cut, from three 
to four pounds of blood accumulated in the cavities, forming 
good clots. 

Without anticipating the appearances of the brain in this 
case, I may remark, that it was examined last, and though 
the veins were numerous and large in its envelopes, yet they 
were nearly empty, owing, probably, to the previous dis- 
charges by the decending cava, (Dissection LXXI.) 

E. M . About an hour after death, the veins being 

distended, blood-letling was performed in the arm, in the 
usual manner, but without a ligature: the stream was of good 
size, and shot up, falling in an arch of four or five inches in 
diameter at first, but, gradually diminishing, it ran down the 
skin of the arm, amounting in about thirty minutes to nearly 
as many ounces, though the arm was elevated above any 



252 



Dowler on Post-mortem Researches. 



other part of the body — it was also lowered — the abdomen 
and chest were opened — the heart was pressed; but, all these 
changes produced none upon the stream, which, becoming 
weaker and weaker, at length ceased. The right side of the 
heart was greatly distended; and the coronary veins upon 
the highest surface of the heart, when punctured, shot out 
blood freely. This subject retained the power of muscular 
contraction for hours after death. (Dissection XCII.) 

0. S . On incising the scalp, the blood ran chiefly 

from the forehead and temples, in a double stream, uniting 
into one, upon the back of the head, nearly as large as a 
goose-quill, and in a few minutes, amounted to about one 
pound: on removing the skull, without wounding the brain or 
its inner envelopes, a like quantity was discharged, with still 
greater rapidity. It happened, accidentally, during dissec- 
tion, that the ligature and compress were removed from the 
orifice of the vein in the arm, from which, five days before, 
he had been bled — the blood spouted forth spontaneously, at 
first in a good stream, gradually diminishing to a slow drop- 
ping in thirty minutes. The orifice was un-united, and had 
a dark color which extended to the surrounding tissue, not 
less than two inches. 

In this subject, muscular contraction continued for several 
hours. (Dissection XCIV.) 

The following case, by some called yellow fever, by some 
congestive, but which perhaps is not referable to either, is 
very remarkable: 

J M , died, from a fever which lasted twelve days 

and a half, and was carried directly to the dissecting table — 
every part of the body was, as far as I could judge, without a 
thermometer, hotter than in health, appearing to my touch, 
nearly as hot as in solar asphyxia. The febrile smell was 
very ofTcnsive, as in the living body, in the most malignant 
fevers. The skin was very white, the tongue moist and pale. 
The external veins, especially those of the arms, were dis- 
tended, as in health after exercise. Two were opened. The 
blood flowed rapidly, projecting several inches, and, after- 



Dowler on Post-mortem Researches. 



253 



wards, more than a foot, by the aids of compression and the 
movement of the muscles of the arm. As the blood cooled, 
a coagulum formed, having a consistent fibrinous, semi-trans- 
parent coat. The cavas discharged about four pounds of 
blood. There was no cadaveric hypersemia. The anterior, 
as well as the posterior walls, and viscera of the cavities, were 
alike supplied with blood. The brain, which was examined 
last, had but little blood, though its vessels were much de- 
veloped, dilated, and moderately distended with air bubbles, 
like the effervescence of soda-water or soap-suds. 

About one hour after the body was placed on the table, a 
free, warm sweat appeared, first, in drops upon the face and 
neck, and then, extended to all parts of the body. The wea- 
ther was mild and pleasant. The cadaveric heat, the liot 
copious perspiration, and the external venous distention, 
afford strong contrasts to the condition of the living body 
-during congestive fever. 

Had this body remained imopened one or two days, what 
would have become of all this blood? To say nothing of 
cadaveric injection, and exudations, the transporting power of 
the capillaries might have deposited the blood in new situa- 
tions, sponging it out from structures that had suffered during 
life from acute hypera^mia, engorging others that had been 
healthy; blanching the former, reddening the latter. At the 
right side of the heart, venous stagnation probably begins, 
and its vessels being wholly passive, it travels outwardly 
towards the extremities of the veins; the capillary power is 
soon neutralized by an opposing mechanical force, or ended 
by the entire cessation of vital action. 

Since cadaveric gravitation aggravates some morbid 
appearances, removes others, and may observe or change all; 
and since the capillary circulation may survive the heart's 
action, and thus, being no longer balanced by supplies from 
the central fountain, may, in a few minutes after death, remove 
morbid accumulations, depositing them in the great veins or 
elsewhere, surely it is important to make post-mortem exam- 
inations as soon as possible. 

2 



254 Dowler on Post-mortem Researches. 

Unusual and protracted heat of the body after death, is, I 
am inclined to think, a presumptive proof that the capilla- 
ries are more or less active at the time. 

J\Iy reason for. dwelling so long upon this subject, is, that 
pathologists have not, so far as I know, adverted to it with a 
view to apply it to post-mortem appearances. Its physiologi- 
cal bearings do not fall within my design at present, and 
though I am not able to appreciate, fully and exactly, its 
modifying agency over morbid anatomy, yet others may be 
more successful in its application. Facts have not been 
sufficiently numerous for exact analysis. 

Another fact which exerts a modifying power over morbid 
appearances, a fact which has been too generally omitted by 
authors, is the following: If the body be warm, the blood 
fluid, a morbid congestion in one cavity may be removed, or 
lessened, at least, in some cases, by severing the blood ves- 
sels leading to another, especially after an acute disease of 
short duration. Let the jugulars, or the cavas be cut, or the 
heart and lungs be removed; in an hour, or less, the brain and 
the abdomen may become more or less bloodless. Though 
the blood vessels may have been previously engorged, and 
their calibers dilated, now, they may appear in a very dif- 
ferent condition, collapsed, and comparatively exsanguious. 
Again, let us suppose, that in two persons recently dead, we 
proceed to examine whether hepatic congestions exist. In 
the one case we open the abdomen; we penetrate the liver 
with the finger, or open its texture with the knife, severing its 
vessels; the blood wells up rapidly, several pounds may flow in 
a few minutes; engorgement seems to be present; and yet this 
happens when there is no congestion at all. In the other case, 
let all the great vessels be divided — let the liver remain in its 
natural situation, and let it be the last organ examined, audit 
will probably be found nearly bloodless; even its parenchyma 
may not indicate the previous congestion. Without regarding 
these circumstances, the former liver would be congested; the 
latter, bloodless or anemic. 

CoT.D, alone, may perhaps remove morbid appearances, and 



Dowler on Post-mortem Researches. 



255 



create mechanical congestions, by unequally condensing the 
solids and fluids of such parts as undergo refrigeration the 
most rapidly — congestions resembling morbid turgescency. 
Cold, acting on the superficial capillaries, and other vessels, 
may force the blood towards the centres, engorging the war- 
mer, and more dilatable parts: even in the living body, cold, 
more particularly congelation, causes paleness or bloodless- 
ness upon the surface, and of course sanguineous centralisa- 
tion. 

Difficulties, in morbid anatomy, result from our limited 
knowledge of the exact appearances of each structure, proper 
to the HEALTHY ANATOMY. Death, from almost any cause, 
whether from decapitation, hanging, drowning, asphyxia, or 
fire-arms, may change the healthy appearances, instantly, in 
many textures. The rarest dissections are those of persons, 
who have died from accidents, not connected with acute or 
chronic diseases. The natural vascularity of a part must be 
estimated, in order to judge whether there be an acquired or 
morbid increase of vessels: so of color, consistence, and 
magnitude. 

In order to acquire just ideas of this branch of the inquiry, 
comparative anatomy is generally available. Some easy les- 
sons may be had of the butcher, at the slaughter house, where 
different animals are killed, by different methods. 

Over-nice distinctions which indicate no palpable differ- 
ences, that millinary of morbid anatomy, retard and discour- 
age the student. 

For example, there has been much dispute about the pre- 
cise color of the mucous tissue of the stomach. This organ 
is one of the most accessible, the easiest examined, one that 
has occupied beyond all others the attention of investigators: 
yet, there exists great difference of opinion, about the healthy 
appearance of its internal coat. "It has been described as 
being white, greyish-white, reddish, greyish approaching fo 
yellow and red, straw-colored, &c. Billard, in whose opin- 
ion Dr. Hodgkin is inclined to place most confidence, states 
it to be a dead milky while. According to Buisson and Bichat. 



256 



Dovvler on Post-mortem Researches. 



the color is a deep red, and according to Sabatier and Habicot 
it is of a reddish purple and deep purple. Gavard, Boyer, 
Soemmering, Chaussier, and Adelon, make it of variable 
shades between red and gray. Rosseau, who derived his opin- 
ion from the examination of the bodies of criminals dying by 
the executioner (by the guUotine we presume), states that the 
color of the gastro-intestinal canal is while, or rather faintly 
tinged with red. We are ourselves rather disposed to agree 
with H. Cloquet who describes the usual appearance of 
the membrane as being oi a. reddish-white ixndinottled — comme 
marhrce." — (British and For. Med. Rev., April, 1841.) 

The COLOR of the internal structures should be noted, soon 
after their exposure to the air. This is a matter of much 
importance, for in a few minutes after the removal of an 
organ from the body, it becomes red or roseate, owing not to 
disease, but probably to its imbibing oxygen gas. This 
acquired color is superficial, and by making a fresh incision 
into the solid viscera as the liver, lungs, spleen, brain, &c., 
some hours after exposure, the original color, as at death, will 
be observed without material alteration. After the frosts of 
October, 1841, this coloration appeared to take place with 
great celerity, and often it assumed a scarlet hue which 
might readily be mistaken for a morbid appearance, by one ^ 
not duly considering the circumstance to xvhich I allude. 

Simple coloration, unaccompanied with structural changes, 
being so variable, is of small value, and is, at the same time, 
one of the principal sources of erroneous deduction in mor- 
bid anatomy. In not a few diseases, the lesions account for 
the cause of death, nearly as well as decapitation. It is bet- 
ter, in doubtful and unexplained cases, to acknowledge our 
ignorance at once, than indirectly to dodge the question, by 
refcring it to slight discolorations, especially such as happen 
to the mucous tissues of the air-passages, stomach, &c., 
which, still more than the skin, are liable to be blanched, or 
spotted with reddish, purplish, and dark hues, from many dif- 
ferent causes, besides the last agony. Seldom, if ever, do we 
see vascular turgcscence or redness of the arachnoid, in the 



Dowler on Post-mortem Researches. 257 



most violent form of the disease called arachnitis, while noth- 
ing scarcely is more common than opacity, thickening, seros- 
ity, sub-arachnoid infiltrations, and especially fibrinous or 
lymphy exudations: the latter product, Professor Gross says, 
"is invariably of inflammatory origin (without our being able 
to detect the slightest redness, &lc.) — a law than which none is 
more satisfactorily established in pathological science.'' (Path. 
Anat. vol. i, p. 59.) 

Cadavkric coloration, is the source of innumerable errors 
in those dissections, where that convenient, theoretical, and 
summary word infiammalion, is vaguely used and much pat- 
ronised, This term is like a sieve for carrying water. It 
may be necessary, in theraputics, as indicating a certain class 
of medicinal agents, but is not necessary in morbid descrip- 
tions, mere descriptions. In the dissection of those white, 
rton- vascular, firm indurations, called scirrhus, I have had some 
experience, and sti^l more in their treatment. In about one 
half of these degenerations of the mouth and neck of the 
womb, the recovery has been complete, by antiphlogistics, as 
absolute diet, position, local irritants, iodine, mercury and 
emaciating medicines, the residue ending in ulceration, and 
death. If the treatment furnish any guide, in judging what 
is, and what is not, inflammation, it would seem that this 
white inflammation offers an excellent type or starting point; 
the redness often found around white indurations may be 
accidental. But whiteness, redness, blackness, &c., do not 
become important unless all the circumstances of the case be 
regarded. In acute fevers in this city, the intestines, particu- 
larly the coecum, colon, and rectum, are often as white as the 
breast of a boiled chicken, or as prepared tripe; and still 
oftener contracted to a round firm cord, scarcely larger than 
the thumb of the subject, and for several feet, so completely 
closed that the French intestinal scissors cannot be introdu- 
ced without much force; the whiteness and contraction be- 
ing the only alterations of the parts. Blackness of the intes- 
tines may indicate mortification, or nothing morbid at all 
beyond mere dyeing, as if it were a piece of cloth; black 
2 * 



258 



Dowler on Post-mortem Researches. 



vomit filling the bowels will sometimes, in from ten to twenty 
hours after death, c??/e all the tissues of the bowels black. Blood, 
according to its accidental hues, will in like manner dye them 
red, claret, mahogany, &c., without any changes of consis- 
tence whatever. 

Mamelonation in its usual and most simple state, is a 
change, the pathological import of which is but little under- 
stood; though, as a matter of fact, it deserves to be noted. 
It consists of eminences much greater than those on the 
surface of the roughest orange, alternating with depressed 
lines upon the internal surface of the stomach, usually of a 
pale white color, though sometimes appearing like red granu- 
lations, at least such are its appearances in the victims of 
fever in this city. It seldom happens. Perhaps a kind of coagu- 
lating or constringing power in the gastric juice, or the spas- 
modic and irregular contractions of those strong, hair-like 
fibres and vessels, which compose the net work of the sub-mu- 
cous tissue, may give rise to this lesion, if such it may be 
called. Cold causes the skin to assume a slight mamelona- 
tion, called "goose-flesh;" alum, gall nuts, &c., causes the 
mucous membrane of the mouth to contract and form irregu- 
lar prominences, apparent fissures, &c. Simple mamelonation, 
without changes of color, cohesion, vascularity, firmness, &c., 
is, in morbid anatomy, probably far less important than 
some imagine. 

The quantity of morbid fluids is often great in yellow 

fever, causing much distention of some organs. B 

C (Dissection XXXVIII), female, of medium size, had, five 

minutes after death, besides six or seven ounces of cere- 
bral serosity and indications of copious ha;morrhages from 
the uterus and vagina, about thirty ounces of blood eflused in 
the pleural cavities, sixteen ounces of blood in the large in- 
testines, and fifty-six ounces of intensely colored, heavy black- 
vomit in the small intestines, in all, about one hundred and 
eight or nine ounces: this coloring matter, in a few hours 
(to say nothing of a day or two), would have spread obscu- 
rity over the morbid appearances of the surrounding tex- 
tures. 



Dowler 071 Post-mortem Researches. 259 



Cohesion, one of the most important and certain tests in 
morbid anatomy, becomes a fallacious guide, under some cir- 
cumstances, chiefly from the effects of delay. If, for exam- 
ple, the muscles have lost their firmness and natural color and 
are becoming puffy, &c., what are we to expect but loss of 
cohesion in other textures, to say nothing of the action of the 
gastric juice upon the gastro-intestinal mucous tissue? The 
medico-legal testimony and pathological deductions, based on 
post-mortem examinations made many days after death, must 
in many cases be involved in great uncertainty. I may be 
pardoned for introducing here the following case as illustra- 
tive of the progress of decomposition in the various organs 
in this climate, inasmuch as it is interesting, I trust, in another 
aspect — showing that the stomach may be ruptured sponta- 
neously without any previous indisposition. 

It is proper to remark, in explanation of a circumstance 
alluded to in the following case, that while travellers face- 
tiously call New Orleans, "the wet grave," its cemeteries are 
really such, excepting those which are constructed with vaults, 
costing from sixty-five to one hundred and thirty dollars each; 
the other cemeteries are situated a mile or more from the river, 
at the termination of the inclined plane, looking towards the 
swamps, in a dead level, the bottom of the grave being at 
about the same height as the low-water mark of the river, 
which circumstance, in connexion with heavy rains and the 
impossibility of drainage, keeps the graves full of water, so 
that bailing out a grave is necessary just before inhumation; 
and even then the funeral service which says, "dust to dust, 
earth to earth," sounds oddly, since the defunct is usually 
committed to the water. In the following case the weather, 
the position, &c., formed an exception, the bottom of the 
grave was made in firm, tenacious mud, and contained a stra- 
tum of water about two inches deep. Had this body been 
exposed to the air, instead of the humid grave, decomposition 
would have been greatly retarded. An opinion has prevailed, 
even in this city, that animal decomposition is unusually rapid 
in our climate. The contrary is the fact, unless humidity be 



260 



Dowler on Post-mortem Researches. 



present. Humidity in this city is sometimes great and sud- 
den, unconnected with rain, amounting ahnosl to a shower 
within doors, owing to the fact, that the north and the south 
winds often meet suddenly face to face; a rapid condensation 
of moisture follows, without fogs however. But more gene- 
rally dessication (from a powerful sun and brisk wind) pre- 
vails at least during autumn. We have extremes, but the 
drying property of our air is very remarkable, and to this 
cause I attribute the slowness of putrefaction which I have 
observed so often, even in hot weather. It appears that in 
some instances where moisture is excluded, the body does 
not putrefy at all. Several years since while engaged in 
collecting materials for the grave-yard statistics of this city, 
the sexton of the Catholic cemetery informed me that on 
opening a vault in the upper tier he found a body, long since 
entombed, completely dried or dessicated, without any signs 
of previous putrefaction: the hair and whiskers firm; the 
eyes and face though dried were of a natural appearance. 
Similar facts have been related by travellers in the east. 
"We observed, (says Captain Lyon in his travels in North 
Africa 181S-'19-'20,) many skeletons of animals which had 
died of fatigue on the desert, and occasionally the grave of 
some human being. All these bodies were so dried by the 
heat of the sun, that putrefaction appears not to have taken 
place after death. In recently expired animals, I could not 
perceive the slightest ofiensive smell; and in those long dead, 
the skin with the hair remained unbroken and perfect, though 
brittle." (Lyells' Geology, p. 119.) 

Having been summoned by the coroner of the Parish of 
Jefferson, to make a post-mortem examination, before a jury 
of inquest, at the McDonald cemetery opposite New Orleans, 
a mile from the river, I proceeded to the place of disinter- 
ment, at 12 o'clock, M., October 1st, 1S42; the weather being 
dry and moderately warm. 

Previous Histouv. H J , a mulatto (whom I had 

attended some years before for gun-shot wound), aged thirty- 
five, resident in New Orleans for twenty years, stout, bony, 



Dowler 071 Post-mortem Researches. 



261 



muscular, with but little adipose tissue, but always healthy — 
workman in the foundry at Gretna — at 8 o'clock, A. M., Sep- 
tember 2Sth, 1S42, after working as usual, ate his breakfast 
of beef-steak, potatoes, bread and coffee, abundantly — left the 
table, walked ten paces, sat down, placed his hand over his 
stomach, knelt down, said he was "devilish sick," the only 
words he spoke; his pulse became imperceptible, his skin cold; 
he was dead, fifteen minutes after finishing his meal; was 
buried the same day; and, by the order of the Judge, was 
disinterred for inquest seventy-six hours after death. ..Before 
reaching the coffin, cadaveric gas becanie intolerably ofl!en- 
sive. ^The coffin was large, strong and apparently tight; the 
corpse, which was much enveloped in cloths — the head in ban- 
dages — filled the entire coffin, except that part corresponding 
to the legs. The coffin contained about one gallon of liquid, 
supposed to be an exudation from the body, being less fluid 
than water, having an oily, bloody, and turbid appearance; 
some of it had leaked out. 

Corpse swollen, puflfy; universal gaseous inflation of the cuta- 
neous, cellular, adipose and muscular tissues doubling the size 
of the body, not excepting the extremities; integuments of the 
face and head from two to three inches thick, lips, ears, and 
eyelids, four inches; the neck, three or four feet in circumfer- 
ence; the scrotum, nearly two; the penis, one; muscles, blood- 
less and softened; great abdominal convexity from gaseous 
distention; foam issuing from the mouth and nostrils. 

Head: hair loose; pericranium and dura-mater non-adher- 
ent, without mucii loss of tenacity; arachnoid and pia mater 
softened; brain like molasses or pus in consistence, being of a 
dirty gray or white color, with sanguineous tints in depen- 
dent parts; this description applies to the upper portion of 
the spinal marrow; the vertebrce were separable by the hand 
alone. 

Chest: lungs, cohesion moderately diminished, color, gray, 
with redness in dependent parts, being greatly collapsed, 
occupying about one-sixth of the cavities; mucous tissues of 
the air passages reddish; bloody effusion, mixed with serosity. 



262 



Dowler on Post-mortem Researches. 



about four pounds; pericardium puffy; heart thin, flabby, pale, 
nearly white, totally empty (as were its great vessels), and 
though its muscular tissue was effervescing with minute air 
bubbles, it was free from elasticity, being only about one 
fourth of the usual size; aoi ta, pleurae, &c., nearly natural. 

Abdomen: intestines distended, pale, bloodless, not tearing 
without considerable force, being moderately softened; the 
mucous tissue pulpy, and free from arborisations, &c.; the 
bile had infiltrated the subjacent tissues; the gall bladder 
empty, its coats putly from gas; the liver was nearly natural 
in cohesion, elasticity and color; the stomach, small and^tten- 
uated, was ruptured about four inches along its lesser^rva- 
ture, it contained about a pint of semi-fluid food; about the 
same quantity had escaped through the orifice (which was 
somewhat irregular, though longitudinal), and lay on the left 
side of the spine near the diaphragm, resting on a clot of 
blood as large as the hand. Here the examination stopped; 
other organs not dissected. 

A few weeks before this occurrence I met with a case of 

rupture of the stomach in the person of T L , aged 

sixteen years. (Dissection LXXVII.) 

I may be allowed to remark that I never had any personal 
experience of the injurious effects of ani?nal effluvia in dis- 
section, except in the above instance. I have known some, 
who, though good operators on the living, have become sick or 
faint from dissection of the dead, even when unattended with 

any strong odors. In the case of J , just related, adepressing 

nausea was produced, somewhat ike sea-sickness, which contin- 
ued for twenty-four hours. Pain in the axilla, nocturnal fever, 
and tedious pustulations do arise from the smallest wound or 
scratch in dissection, the dangers of which, however, have 
been greatly exaggerated, if I might speak from what I have 
seen. 

Gaseous distention of the tissues, though generally the 
effect of incipient decomposition,. is not always so. I hnve 
seen it in five minutes after deaths the most rapid in bodies 
that appeared as free from all the appearances of putrefaction 



Dowler on Post-mortem Researches. 263 



as if they had died from a ball through the brain. It appears 
in the sub-mucous tissue of the stomach, in the blood ves- 
sels of the brain, in the cellular tissue of the neck, and in 
the heart. 

In pathological anatomy, still more than in geology, dif- 
ficulties arise in the chronological classification of strata; 
primary, secondary, and recent morbid formations, being 
often mixed and confused, their eras are uncertain. 

As in weights and measures, so in healthy and morbid 
anatomy, standards of comparison are desirable. In these 
dissections, I have often in the absence of any known stan- 
dards, endeavored to introduce some, though not very pre- 
cise. Thus, when I speak of the tenacitij of the arachnoid 
and pia mater, I mean that they may be peeled from the 
hemisphere and its depression entire, or nearly so, and that 
a strip raised on the handle of a knife from one to two 
inches in breadth, will be strong enough generally to sus- 
pend the half or the whole brain without rupturing. 

With respect to hypertrophy or enlargement of the organs, 
they are compared with recollections and with the best de- 
scriptions of their size in a healthy state; thus, it is said, 
their dimensions are augmented one-third, one-half, twice, 
&c. All this is very inexact; precision is impossible. In 
different individuals the organs differ in size, in the healthy 
state. But is not such a standard better than none? 

With respect to several of the holloio viscera, particularly 
the stomach, considerable thickness and contraction, or thin- 
ness and distention, may exist without necessarily implying 
any morbid change. An empty stomach is generally very 
thick, its mucous surface wrinkled, and full of fold or plaits; 
on the contrary, the presence of much fluid is attended with 
attenuations of its coats. By inverting this organ, and fill- 
ing it with air or water, its sub-mucous tissue may be infil- 
trated by pressure, so as to become one or two inches thick 
resembling ecchymosis, oedema, emphysema, &c. This 
tissue is the seat of those arborizations, which have been so 
often erroneously ascribed to the mucous membrane. 



264 Dowler on Post-inortem Researches. 



I have not seen in this membrane well-marked vascularity 
that is, a net work of continuous trunks and branches, as in 
the conjunctiva, seious membrane, and other tissues; when 
the sub-mucous tissue has suffered denudations from loss of 
its mucous membrane by ulceration, softening or otherwise, 
or when this latter is more or less transparent, arborizations 
may appear; they are in fact, often almost naked, surviving 
the wreck of the disorganized tissues to which they had be- 
longed. However red, hard, and swollen the mucous mem- 
brane may be, by disintegrating it gradually by scraping, the 
blood appears in minute points or dots, widening as you pro- 
gress outwardly, appearing like cones with their apices 
pointing towards the centre of the stomach, their bases rest- 
ing in the outer half of the sub-mucous tissue, where a layer 
of vascularity spreads over the inner surface of the muscular 
coat in acute hyperaemias of this organ. 

It is a very great error, in a scientific point of view, 
whether in public or private practice, to pick or select sub- 
jects for dissection, on account of something extraordinary in 
the previous history or in the external post-mortem anatomy, 
for by so doing we keep among the exceptions, not the gen- 
eral rules; we study monstrosities, not the common run of 
cases. Few, indeed, can expect out of the irregular to es- 
tablish its regular laws, as St. Hilaire has done in mon- 
strosity itself. 

As a modifier of post-mortem appearances, treatment is, 
doubtless, a very important subject of investigation; a treat- 
ment essentially wrong, aggravates, seldom creates the mor- 
bid appearances, while the proper treatment lessens their 
natural tendency more or less. For example, whatever good 
or bad effects quinine may have in yellow fever and other 
fevers, given in doses ranging from one grain to two drachms, 
it appears not to create certain morbid appearances, which 
some ascribe to it instead of the malady. Serosity of the 
brain, opacity and tenacity of the arachnoid — vascularity, 
thickness, infiltration, and firmness of the pia mater, acute 
hyperasmia of the stomach, &c., are not attributable to that 



Dowler on Post-mortem Researches. 



265 



mode of treatment. The candid Eclectic will need humili- 
ty and patience when he comes to compare and count organs 
with the Quininian, the Sanguinarian, the Inertiarian, the 
Hydrargian, the Non-medicationist of the Method Expec- 
tante, and other exclusives. In these dissections, to which 
I have so often alluded, nearly evei~ij mode of treatment 
is represented and reflected: in some, no treatment, or 
one wholly palliative was adopted. When a physician, 
wedded to a particular school of practice, "who has made 
up and expressed an opinion" in regard to his late, but now 
defunct patient, comes to the examination and bears testimony 
against himself, he is doing more than any court in Christen- 
dom exacts under oath. Rochefoucault says, "we need not 
be much concerned about such faults as we have the courage 
to own." A man who dissects none but those who have 
died under his own peculiar treatment, to say nothing of the 
biases of pride and theory, must of necessity take a one- 
sided view, calculated to foster that narrow Idealism which 
is, in medicine at least, a concentrated impersonation of 
all that is Real, since it opens the veins, blackens the body 
with leeches, marches into our vitals with the strongest 
preparations, compatible and incompatible, that chemistry 
can produce. 

Prof. Graves, of Dublin, strongly insists upon the neces- 
sity of morbid anatomy to correct these narrow views of the 
mere symptom-hunters. "Medicine has followed medicine, 
each symptom has been the object of attack, until death ap-. 
proaches with accelerated step, and charitably closes a scene 
distressing to humanity and disgraceful to the cause — I was 
going to say — of science; but who will give so ennobling 
a name to this pseudo-practical knowledge — this worse than 
absolute ignorance. I am not combating phantoms; I do 
not Quixote like contend with imaginary giants; no, what 1 
have described exists; the picture I have drawn has many an 
original." 

Theoretical words lead to latitudinarian and erroneous re. 
suits, and should be excluded from dissections altogether. 
3 



366 



Dowler on Post-mortem Researches. 



The physical appearances alone must be given — accurate 
descriptions, as in the science of geography, the morbid and 
healthy geography of organs. 

I have, in these descriptions, avoided the word inflamma- 
tion, a word that even now is so vaguely applied, as to include 
the most opposite appearances in color, consistency and size. 
When an organ is blanched, reddened, thickened, thinned, 
softened, indurated, brittle, tenacious, tumefied, ulcerated, 
puffy, excavated, infiltrated, perforated, enlarged, diminished 
or otherwise altered, the fact is so stated, together with all 
its accompanying physical characteristics. This mode, 
though not very summary and compendious, is in conformi- 
ty with the dictates of common sense. Let not the matters 
of fact be confounded with the matters of opinion. 

Let us illustrate this matter: — S B. E , of Mas- 
sachusetts, aged 19, who died of yellow fever, August 6th, 
1842, the first fatal case in the epidemic of the season, and 
who was dissected seventy-five minutes afterwards (by Drs. 
Wederstrandt, Fenner, Slade, Saunders, and myself — Dis- 
section LXXIII), presented the following appearances of the 
mucous membrane of the stomach: — "One-third of the mu- 
cous membrane, and of the sub-mucous tissue next to the 
cardiac orifice, were of a deep claret color; when scraped, 
innumerable small bloody points appeared, without arbori- 
zations; the entire membrane having a natural consistence, 
thickness, and tenacity, peeling in strips an inch long, leav- 
ing the muscular coat natural (dull white), except a red- 
dish spot, corresponding to a button-shaped clot of blood, 
as large as a dime, which formed a dense infiltration of the 
sub-mucous tissue, with the filaments of which it was inter- 
sected.'' Now, with the exception of this ecchymosed spot, and 
the intense coloration, all the coals were healthy, free from 
thickening, pufTmess, softening, ulceration, induration, or other 
departure from the natural state. Here (omitting the but- 
ton-shaped extravasation, often met with,) we have one ele- 
inent of inflammation. But, is color, per se, an indubita- 
ble proof of the presence of inflammation, in the absence 



Dowler on Post-mortem Researches. 



267 



of all structural alterations whatever? One pathologist may 
call the above appearance inflammation of the stomach; 
another may deny this as positively, or doubt as to its patho- 
logical character. What must an honest dissector do in the 
premises? Let him describe the physical appearances truly, 
instead of deciding the pathological question, by writing 
down the word inflammation. Stronger cases might be mul- 
tiplied, showing that slate-color and even deep black (some- 
times in the form of a very fine, dust-like, powdered charcoal 
imbedded in the mucous tissue) — arterial, venous, claret, ma- 
hogany and other colors, exist independent of any apprecia- 
ble changes of structure. 

The word congestion, in its application to the brain, is very 
often misunderstood, so as to imply a physical impossibility. If 
the brain when the circulation is natural, be a plenum, or nearly 
so, as it is admitted to be, and is like water, incompressible, then 
general congestion, from an absolute augmentation of blood in 
the cranial cavity,cannot happen unless the bones be separated: 
the relative situation of the blood changes, not its quantity. 
The meningeal artery is by a blow ruptured — a broad clot 
extends over a considerable portion of the brain; a blood ves- 
sel spontaneously ruptures in the substance of the brain (apo- 
plexy), forming an irregular coagulum as large as the fist; or, 
serosity accumulates to the extent of half a pound: but such 
accumulations in one part must exclude or displace just as 
much blood from entering the brain to other parts during life. 
I have seen more than a hundred instances of serosity of the 
brain, with vascularity of the pia mater; but if the serosity be 
great, usually the blood vessels are collapsed. So of that 
doubtful lesion called hypertrophy of the brain: if any real 
enlargement happen, it is probably at the expense of the 
general circulation, by excluding from the arteries and veins, 
great and small, an equal quantity of blood. 

Many of the French pathologists have adopted a nomencla- 
ture, in many instances very convenient, and expressive of 
general conditions or states of morbid alteration; not much 
is gained, however, by adopting such words as acute hyperce- 



268 



Dowler on Post-mortem Researches. 



mia, chronic hypertemia, as substitutes for acute and chronic in- 
jlammaiion. In order to avoid endless repetitions, I have 
been compelled to write the word healthy or natural, imme- 
diately after the organ mentioned, without describing the 
characteristics of healthy anatomy, particularly in relation to 
some of the less important structures, as the lymphatics, pan- 
creas, kidneys, bladdei-, &c., though in all doubtful cases 
the dcscr-iption is given* 

The average time required to make a dissection with care, 
including the time for pencil notes, and then copying, is about 
four hours. It is true that in the ordinary mode of proceed- 
ing, the stomach, &., may be seen in as many minutes. But 
it is quite a different affair, to examine, to remove, and then 
re-examine each organ, opening every inch of the bowels, 
washing, macerating, holding up in the sun every part, &c. 
Louis says, "practice in order to collect observations, is a 
trade, and like all other trades must be learned, and cannot 
be divined." A theoretical abandon is proper in making a 
dissection; after it has been faithfully recorded, let it be as 
completely forgotten as possible while making the next. 

The laborious, and to some, repulsive character of these 
necessary studies, should not deter the conscientious student; 
for though he should not increase his gold thereby, yet he 
will deserve it honestly; the difficulties incidental to these pur- 
suits, in thinly inhabited country situations are almost insur- 
mountable, and therefore a resort to cities for this purpose is 
desirable before settling down for life. For this purpose New 
Orleans is unsurpassed by any city in the Union. Here, 
there is no prejudice against dissections. Her great Charity 
Hospital offers practical facilities on the largest scale. Every 
young physician in the south and west, may also furnish him- 
self (without cost) all necessary anatomical preparations. 

The Dead-House, situated in the rear of the Charity Hos- 



* If the average number of healtliy organs in each case of dissection amount 
to twenty, then two hundred cases will amount to four thousand instances, re- 
quiring as many special descriptions, unless we adopt the word healthy or natu- 
ral, in order to avoid repetitions. 



Dowler on Post-mortem Researches. 



269 



pital, in a noisless and unfrequented spot, and consequently 
favorable for post-mortem investigations, is divided into two 
apartments, called the reception and the dissecting rooms. 
In the former the corpse i? deposited on a stone floor, by two 
men whose business it is to coffin the dead. The bodies of 
males are covered with a sheet only, which is removed before 
the corpse is placed in the coffin; females are always furnish- 
ed with garments in which they are buried. If, as rarely 
happens, the friends of the deceased wish to bury the body, 
a ticket is placed over its breast by order of the clerk of the 
Hospital. The dissecting room is ventilated, sky-lighted, and 
supplied with tables and water. How different from the agi- 
tation, noise, confusion, and hurry, incidental to post-mortem 
examinations in private practice! Here, the operator is not 
dismayed by the fear that each sound of the saw or hammer, 
will be echoed back in a sob or a shriek by some relative of 
the dead, in the adjoining room. 

In the dead-house, Europe, Asia, Africa, and America are 
all represented. The Caucasian or European face, fair and 
symmetrical, is by far the most common; the Irish, German, 
French and English greatly predominating, the Mongolian or 
olive Asiatic, and the African, being most infrequent. 

Here, in yellow-fever seasons, the mountaineer of Switzer- 
land, the low lander of Holland, the Swede from the icy cir- 
cle, the Mexican from the tropics, the New Englander from 
his blue hills, and the country Creole from his black swamps, 
the virgin just arrived at womanhood, and the matron who 
has not yet passed the meridian of life, lie, side by side, with 
the saddest features, as if reproaching us for not saving them 
from an untimely grave. In this contemplation of the dead 
body upon a large scale, where many, the young, the robust — 
victims of a single night — lie crowded together, one naturally 
is reminded of what Moliere makes Beraldo, in the Maladie 
Imaginaire, say: "I do not know a more pleasant piece of 
mummery, or any thing more ridiculous than for one man to 
undertake to cure another." 

The dead-house, it must be confessed, produces a little skep- 
3 * 



270 Dowler on Post-mortem Researches. 



ticism, but it is a wholesome skepticism when making an ex- 
ploration into the realms of death; even systematic anatomy 
will abate something of its pretensions on the score of oracu- 
larity. The observer finds irre^wZan/ies of structure accumu- 
lating on his hands, with surprise, unless he belong to that 
class, that nothing medical can surprise. One of the greatest 
anatomists denies that the testicle is ever missing or single, 
yet I have met with such a case; also a man with organs of 
generation unmarked with any sign of puberty, being in the 
infant state of development; a woman with one kidney; in 
another it was wrong side up; the stomach adherent to the 
uterus, and irregularities too numerous to mention. One 
irregularity, referable to morbid anatomy, I will here mention 
at the risk of being suspected of leaning towards the marvel- 
lous. Depending on memory alone (not having leisure at 
this moment to make an exact estimate), I suppose that about 
ten per centum of those dying of fevers in this city, have 
from one to four complete intussusceptions in the small intes- 
tines, sometimes six inches in extent, at least such has been 
one of the results of my observations. 

I append the following analysis of the color of the liver in 
yellow-fever, not that it is equal to many other appearances 
of this and other organs, in pathological importance, but, be- 
cause it happens to be the most convenient. For though I 
am collecting facts on fevers and bowel-complaints, and have 
copied many into the anatomical portion, I have not analysed 
them with precision. However, I am sure there is no mate- 
rial error in this enumeration. The terms and comparisons 
used are more or less varied in the original. 

Yellow, as orange, lemon, straw, brass, gingerbread, 

cork, 54 

Yellow and milky, 3 

Nutmeg and straw-yellow, - v - - - 4 

Brown and yellow, 2 

Brown and yellow, with lines or streaks, - - - 2 
Yellow, milky, and mahogany, with lines, - - 1 
Yellow and healthy, mixed, 1 



Dowler on Post-mortem Researches. 



271 



Bronze and reddish, 4 

Pale brown and mahogany, 9 

Purplish and brown, 1 

Mahogany and white, 3 

Chocolate, 4 

Flaxseed, 5 



Dark, 1 

Reddish, brown (nearly healthy), - - - - 1 

Black and brown, 2 

Dark, mustard, 1 

Black and purple, 1 

Greenish and chocolate, 1 

Dark and greenish (stratified), - - - - 2 

Lead-color, 1 

Purple and white, 1 

Accidental omissions (in making notes), - - 4 
Healthy or natural (that is, brown, with slight 
reddish tint externally, and a yellowish tint in- 
ternally), - 6 

Total examinations (yellow fever). 

The liver presents many other points for analysis, as to 

size, cohesion, membranes, ansmia, hyperemia, &c.; also, 
oyster-like degenerations of the gall-bladder, effusions of albu- 
men into that cavity, and other important alterations. 



* These researches, so far as mere color of the liver is concerned, agree 
in many instances, with those of Louis on the yellow fever of Gibraltar, in 
1828; but more generally they are very dissimilar, especially upon the brain, 
haemorhages, &c., a fact admitting of satisfactory explanation, without calling 
in question the accuracy of the commission (of which Louis was one), 
sent by the French Government to Gibraltar, in 1828, for tlie purpose of in- 
vestigating this malady. Their post-mortem examinations were, I beheve, 
nearly all made in the winter, when the epidemic had declined, or nearly so. 
Except in a single case, they did not, personally, observe the ante-mortem 
or previous history, and, among their 23 or 24 cases they mention a 
number as not being yellow fever, as the 13th, 15th, 18th and 24th, and, per- 
haps, some others. CI quote from memory.) Besides, the yellow fever of 
Gibraltar and that of New Orleans may differ from each other. 



114* 



272 



Dowler on Post-mortem Researches. 



I have not, in this paper, even glanced at the morbid ap- 
pearances of the FLUIDS. The stupendous conclusions at 
virhich certain pathologists seem to have suddenly arrived, ap- 
pear defective in one essential matter, evidence, facts. Even 
oxygenation, carbonization, de-fibrination, super-fibrination, 
&c., are better known than appreciated in morbid anatomy. 
But the new chemical metaphysics by which the "alkaloids 
of opium," "quinine," &c., become chemically combined or 
converted, or transformed into brain and nervous matter, and 
then cure chemically by diminishing oxygen, &c., are quite 
too transcendental for a poor dissector, though well enough 
adapted to flourish in the realms of German idealism, where 
the genuine Monades are said to exist, out of which it is 
gravely declared a god will some day be created, if one 
do not exist already. 

With the words, black blood! carbonized blood! putres- 
cent blood! still ringing in our ears, we begin to hear of 
blood too rich, too fibrinous, over charged with oxygen — (the 
sensible appearances lean a little towards the latter) — but 
the easy mode of setting aside the utility of dissections, by 
referring diseases to the nervous system unaccompanied with 
any alterations of structure, is an explanation requiring ex- 
planation: and so of the fluids. I would like to see the hu- 
moralist that can distinguish, by sensible appearances, the 
blood of a yellow-fever patient from that of the most healthy 
man; yet they are not always alike. 

January, 1843. 



jJtt)ltoflrc{|)iitcal Notices. 



Art. II. — A Therapeutical arrangement of the Materia Medica; 
or the Materia M-dica arranged upon Physiological Princi- 
ples, and in the order of the general practical value which 
remedial agents hold under their several denominations, and 
in conformity irith the Physioloo-ical doctrines set forth in 
the Medical and Physiological Commentaries. By ^Iartyx 
Paixe, ]M. D., a. M., author of the Commentaries, and of 
the Letters on the Cholera Asphyxia of New York, and 
Professor of the Institutes of jNIedicine and Materia ]Medica 
in the University of New York. Xe\\ York: J. &. H. G. 
Langley, .57 Chatham Street, 1S42, p. 271 duodecimo. 

This little volume presents as fair a claim to the motto, 
"multum in parvo," as any production of the American press, 
or indeed of any press, that has fallen under our notice. And 
it contains, for its size, not only a large amount of matter, but 
matter of a practical and valuable character. Were we in- 
clined to appear, on the occasion, either classical or poetical, 
or both at once, we might correctly enough apply to it the 
distich of the great and accomplished Mantuan, in his poem 
on bees; 

"In tenui labor; at tennis non gloria, si quern 
Numina Iseva sinunt auditque vocaliis Apollo." 

The title-page itself of the work so far discloses its charac- 
ter and design, that our readers need but little more for the 
attainment of a competent knowledge of them. From that 
page they will at once perceive, that Professor Paine is a tho- 
rough-bred and uncompromising vitalist. Hence they cannot 



274 



Paine's Materia Medico. 



fail also to learn from it that he considers the science of medi- 
cine as consisting in a true and complete exposition of the 
laws of living organized matter; and liie practice of medicine 
in a correct application of those laws to the treatment of dis- 
eases — the means of treating tliem being derived from Mate- 
ria Medica. And they will further be made sensil)le, that, as 
a writer and teacher, he denies the existence of any identity, 
connexion, or even close analogy between the philosophy of 
living and the philosophy of dead matter. In more express 
and definite terms, they will tlius learn, that he regards physi- 
ology, in its principles and laws and their mode of action, as 
essentially different from those of either chemistry or the sci- 
ence of mechanics; and as being an exposition of functions 
exclusively vital. 

Still however, though so much, respecting the character 
and design of the volume may be ascertained from the title- 
page, we think it best to lay before our readers a briel' extract 
from its preface, in more definite explanation of them. 

"These purposes" (those of the work we are considering) 
are mainly: 

"1. To arrange the Materia Medica upon intelligible, phys- 
iological, and therapeutical principles. 

"2. To indicate the relative therapeutic value of the vari- 
ous articles, under their different denominations, by arranging 
them in the order of their value. 

"3. To give to the student a comprehensive and ready view 
of the merits of the various articles composing the Materia 
Medica, and of their relations to each other physiologically. 

"4. To supply a convenient means of graduating the doses 
of medicine." 

From that portion of the work which is headed "General 
principles," we shall also make a brief extract, our object in 
doing which will presently appear. 

"1. All remedies operate upon the same principle as mor- 
bijic agents, and all become morbific when injudiciously ap- 
plied. Applied to healthy systems, they alter the vital pro- 
jjcrties and actions so as to constitute disease. * * * "Modi- 



Paine's Materia Medica. 



275 



cines" says Linnceus, "differ from poisons, not in their nature, 
but in their doses." And so Pliny; ^'ubi virus, ibi virtus" 

"3. All curative agents operate upon the morbid properties, 
either directly or indirectly through sympathy, and produce 
their salutary results, by so altering the morbid properties, as 
to enable them to take on their natural tendency to a state of 
health." 

These three last quoted paragraphs show our author to be 
a liberal, bold, and independent thinker; and we fully concur 
with him in the sentiments they express. Medicine and poi- 
son are but different names for the same article, according to 
the quantities and modes in which, and the circumstances 
under which it is administered. And all remedies which 
actually change disease are necessarily alteratives, from the 
nature of the case, and the meaning of the term. 

As relates however to the third paragraph, our coincidence 
in opinion with the Professor is not quite so entire. At least 
we do not like the expression "operate on properties" whether 
they are morbid or healthy; because we think it calculated to 
make an erroneous impression. Agents do not act immedi- 
ately on "properties," which have no existence apart from the 
substances to which they belong. They are but the attrib- 
utes, signs, or shadows of such substances. To operate on 
theyn therefore is tantamount to operating on a non-entity. 
The operation is on the substance and the change produced is 
in the substance; and the properties of course experience also 
a corresponding change; because as is the substance, so neces- 
sarily are they. This is true of all properties, whether the 
substances they belong to be living matter or dead matter. 

In illustration and proof of this, let us consider for a mo- 
ment the properties of elasticity and weight. We cannot 
operate immediately on them. To change them, we must 
change the substances to which they belong. The produc- 
tion of an alteration in properties then is of necessity an in- 
direct process. The reason is plain. It must reach them 
through the substances to which they appertain. 

We should not have noticed this error in mere words, had 



276 



Paine's Materia Medica. 



they been the words of an ordinary writer; or had they been 
employed but once even by Professor Paine. In either case 
we might have regarded them as slips of the pen, and allowed 
them to pass without animadversion. But the Professor is 
able in intellect, and distinguished and influential as a writer 
and teacher, and has repeatedly used them in the course of 
his work. His errors therefore, whether in words or thoughts, 
are of bad example, and dangerous, because they lead weaker 
minds astray. Hence their rectification is necessary and im- 
portant. 

Professor Paine arranges the articles of Materia Medica 
under twelve heads, which he denominates and classes in the 
following order, and under the names attached to them. 

"1. Antiphlogistics. 2. Permanent Tonics. 3. Difl'usible 
Stimulants. 4. Cerebro-Spinants, or Nervous Agents. 5. 
Astringents. 6. Uterine Agents. 7. Urinary Agents. 8. 
Anthelmintics. 9. Errhines. 10. Chemical Agents. 11. Diet 
and Regimen, in a general sense." 

This arrangement (and we presume not to say that it can 
well be improved) does not amount to a complete execution 
of our author's plan, already communicated in his own words. 
It does not we mean, in every particular, strictly conform 
to physiological requirement. This is the case with the 
class of 

"Tonics," that term not being properly applicable to living 
matter in any condition it can be made to assume, but to dead 
matter in a state of tension. This may be illustrated by 
the condition of well prepared bows, and by that of drums, 
harps, violins, and other instruments of music. These seve- 
ral instruments must be in a "tonic," that is a tense condition, 
when well fitted for the purposes for which they are de- 
signed — the first to lanch the arrow, and the others to send 
forth well-conditioned musical sounds. As regards the condi- 
tion of the bow and bow-string, the cords of the harp and 
violin, and the head of the well-braced drum, nothing at all 
analogous to it is produced by the action of "Tonics" on any 
portion of the human body. In the condition of a healthy 



Paine's Materia Medica. 



277 



and vigorous muscle, nerve or gland, there is no more of tone 
or tension, m the true sense of the terms, than there is in the 
condition of a deranged nerve or muscle. The word tone 
belongs to mechanical, not to vital philosophy. Still, however, 
provided we divest it entirely of its literal, mechanical, and 
coarse meaning, and so interpret it as to signify soundness 
and excellency of condition, it may, without communicating 
such mechanical views as are highly injurious, be applied to 
vital matter. And we confess our inability to substitute for 
it a better term. 

We fully however concur with our author, that what are 
called "tonic" remedies are greatly overrated, as relates to 
their usefulness. In many cases, especially of chronic dis- 
eases, they may, and we doubt not do, as alteratives, prove 
serviceable. But, from the injudicious manner, in which they 
are exhibited, we have long been convinced that, in conva- 
lescence from acute disease, they do an immensity of mischief. 
Indeed, in such cases, provided the complaint be sufficiently 
deracinated, by antecedent means, they [are wholly unneces- 
sary; and usually injurious. When, by a judicious treatment, 
an acute disease is brought down to the proper point, nature 
by her recuperative energies, most safely and effectually 
completes the cure. The best tonic under those circumstan- 
ces is a well directed regimen and form of diet. Every thing 
beyond tiiat embarrasses nature, and impedes her in her 
eiforts to remove the complaint. Nor is this view of the mat- 
ter at all inconsistent with the fiict, that tonics are efficaciously 
employed in the treatment of intermitting and remitting 
fever. That, even in those complaints however, tonics, un- 
skilfully administered, are productive of much mischief, is a 
circumstance familiar to every experienced practitioner of 
medicine. 

To the class-term "Astringents" similar remarks are cor- 
rectly applicable. It is not, in its import, strictly physiologi- 
cal. True; the articles thus denominated produce an astric- 
tive effect on the lips, tongue, and fauces of those who swal- 
low them. But there the astrictioa stops. Though the func- 
4 



278 



Paine's Materia Medica. 



tions of the system may be afiected by the article, the affec- 
tion is alterative, not astrictive. 

To the class-term "Anthelmintics" also exception may be 
taken on the same ground. It bears no direct relation to 
physiology — certainly none to the physiology of man, what- 
ever may be its relation to that of other animals. It signifies 
articles deletereous to worms, and nothing more. Of the effect 
of those articles on the human system it is in no way expres- 
sive. 

Let it be distinctly understood however, that these ani- 
madversions on some of his terms are not to be construed into 
a sentiment of disapproval toward Professor Paine, as a wri- 
ter. Far from it. We do not remember any terms more 
suitable that might be offered as substitutes for those to which 
we have excepted. The defect in the class-names arises much 
more from the intractable nature of the case than from «ny 
fault in our author. The result is therefore matter regret, 
because it cannot be amended, rather than of Wame, because it 
is not. 

With the Professor, in his views respecting "Cold" we can- 
not concur. lie arranges and treats the article as a direct 
sedative. We, on the contrary, regard it as a direct stimu- 
lant and an indirect sedative. To the nerves it is not only a 
direct, but also a very powerful stimulant. It may be made 
to produce keen and intensely painful sensations — a result 
which cannot possibly be the product of a sedative. 

Nor is cold a stimulant to the nervous tissue alone. It also 
acts most powerfully as such on the vascular system. When 
carried to a sufficient extent, it not only burns, but actually 
blisters. A piece of frozen quicksilver received into the hand 
burns and blisters like red-hot iron — an effect totally foreign 
from the influence of a sedative. 

Frozen quicksilver and red-hot iron however, although they 
produce the same eflect on the hand, do so in modes the very 
reverse of each other. The iron burns and blisters by pour- 
ing caloric superabundantly into the hand; the quicksilver by 
drawing caloric superabundantly out of it. In doing this it 



Paine's Materia Medica. 



279 



brings the caloric, in a large amount, to a focal point, in 
consequence of which it acts like the solar rays, brought to a 
point, by a powerful burning lens. 

Such are our views respecting the mode of operation of 
frozen quicksilver. And whether they are right or wrong, 
the fact they relate to is certain. The quicksilver which is 
intensely cold, excites a blister. But this it could not do, 
were it not a stimulant. 

Cold is an antiphlogistic remedy, because it is an evac- 
uant. And, so far as they are evacuants, all medicinal 
substances are antiphlogistics — as necessarily and essen- 
tially so, as blood-letting itself — though not in an equal de- 
gree. 

Blood-letting alone excepted, all evacuations from the 
body are the offspring of secretion. Except the fa;cal 
discharge, evacuation is but the discharge of secreted mat- 
ter. 

If this be true (as it unquestionably is) secretion is na- 
ture's chief mode of removing inflammatory affections. 
Thus the secretion and evacuation of bile cure hepatitis. 
The secretion and discharge of mucus aid in the removal of 
the several kinds of thoracic and pulmonary inflammation, 
A superabundant secretion and evacuation of saliva take 
down inflammation of the salivary glands. A copious secre- 
tion and discharge of urine aid in the cure of nephritis. 
The secretion and evacuation of pus contribute to the cure of 
the inflammation and congestion attendant on abscesses. 
And the secretion and discharge of perspirable matter aid in 
the removal of every affection to which man is subject. To 
the cure of all febrile affections they are indispensable. 

From these considerations we have long been of opinion 
that there is just ground for the formation of an order at 
least, if not a class of remedies, under the denomination of 
SECRETORiEs. And it would be an extensive and important 
one. For we venture to say that every remedy, which con- 
tributes to the cure of a general disease, does so, to no small 
extent, by throwing into natural and healthy action some of 



280 



Paine's Matei^ia Medica. 



the secreting organs of the body. Hence arises what is de- 
nominated, by most of the ancient medical writers, and by 
not a few of the modern ones, the critical discharge. And 
though the regular occurrence of such discharge is even 
tauntingly discredited, by many physicians of the present 
day, it is notwithstanding true. The evacuation comes most 
frequently from the liver and alimentary canal, the mucous 
lining of the trachea and lungs, the kidneys, or the skin. But 
no matter whence it comes. Its existence is certain. And 
when of a local character, as it often is, it proceeds from 
the organ, or its neighborhood, where the deepest conges- 
tion exists; and it relieves or removes that congestion. 

The critical discharge is the product of nature; not of med- 
icine. Nor does the good it effects arise from, or depend on, 
either its quantity, its kind, or its quality — nor from all these 
attributes united. It is to be regarded but as indicative of 
good, as evidence we mean that the course of action in the 
system of the sick is changed. And that change of direc- 
tion is from cenlripelal to centrifugal — a change which is 
always salutary and of good promise. In febrile complaints 
the course of action is from without to within; and usually 
secretion of every description is restricted. And when the 
action changes its direction, from within to without, the se- 
creting organs are thrown into operation again; and the result 
of that change is the restoration of health. But we can pur- 
sue this desultory notice no farther. In a few general and 
brief remarks, therefore, we shall bring it to a close. 

The volume we have been considering, though small, ex- 
hibits notwithstanding a large amount of acquired knowl- 
edge, and no small degree of strong, independent, and well 
matured thought. Its arrangement, and the peculiar tenor of 
its doctrines and directions, are entitled to our entire and de- 
cided approval. We regard it, however, as little else than 
a syllabus or text-book for Professor Paine's course of lec- 
tures on Materia Medica. And, as such, we deem it pecu- 
liarly valuable to the pupils to whom those lectures are de- 



Churchill on the Diseases of Females. 



2S1 



iivered. To ihem, during their pupilage, it will prove a 
highly convenient and useful companion in the Professor's 
class-room, as well as in their own studies, and even when 
subsequently engaged in professional practice, a ready and 
abundant remembrancer of what they have already learned. 
Nor, limited as the work is on every topic, will even those, 
who have not attended the lectures of its author, fail to de- 
rive from a careful perusal of it many important and some 
new philosophical views of Materia Medica. In these re- 
spects, therefore, the volume is cordially recommended to 
public attention. 

C. C. 



Art. III. — The Diseases of Females: including those of Preg- 
nancy and Childbed. — By Fleetwood Churchill ,M. D., 
author of the "Theory and Practice of Midwifery;" Licen- 
tate of the King and Queen's College of Physicians in 
Ireland, &c. &c. Second American edition. With notes, 
by Robert M. HrsTox, M. D., Professor of Materia Medi- 
ca and General Therapeutics, &c. &c. 1 vol., 8vo., pp. 
575. Philadelphia, Lea & Blanchard, 1843. 

The two parts of which this volume is composed were 
originally published separately, that "On the Diseases of 
Females" first, followed after an interval by the "Diseases 
incident to Pregnancy and Childbed." They are very prop- 
erly combined in the present edition, and constitute by far 
the most complete and systematic work on the subject that 
we know. Both are compilations for the most part, and 
do not claim to be any thing more. The author has 
intended to make the work acceptable both to the junior 
and senior student; to this end, to use his own language, 
"it has been arranged, in the present volume, that the teat 
shall contain an ample outline of the history, pathology, 
symptoms and treatment of the diseases, without any detail 
of controversies or conflicting opinions, which are given in 
full in the notes appended to each page; so that the junior 
student, by confining his attention to the text, may acquire 



282 



Wistar's System of Anatomy. 



elementary information, which may be subsequently extended 
by consulting the notes and references.'' 

The notes of the American editor are not very numerous, 
but pertinent, and we would add judicious, if we had not such 
a horror of the word. C. 



Art. IV. — A System of .Anatomy for the use of Students of 
Medicine. By Caspar Wistar, M. D., late Professor of 
Anatomy in the University of Pennsylvania. With notes 
and addilions. By William E. Horner, M. D., Professor of 
Anatomy in the University of Pennsylvania. Eighth edi- 
tion. Entirely remodelled , and Illustrated hi/ more than two 
hundred engravings. By .T. Pancoast, M. D., Professor 
of General, Descriptive and Surgical Anatomj' in Jefferson 
Medical College, etc. 2 vols., 8vo., pp. 538, 622. Phila- 
delj)hia: 'J'homas, Covvperthwait & Co.; 1842. 

Dr. Wistar's Anatomy lias always been a favorite with 
students, and has accordingly passed through numerous edi- 
tions. Indeed it has been worked over so often, that we can 
scarcely recognize it as the book with which we began our 
professional studies; even at that lime it had been more or 
less changed by editors. 

Professor Pancoast has retained the matter introduced by 
the former editor. Professor Horner, to which he has added 
a large amount of new matter, compiled from various sour- 
ces, chiefly in relation to general and microscopic anatomy, 
the latter of which has been for some time and is now attract- 
ing so much attention. The work is fully brought up to the 
existing stale of the science. It is embellished by the intro- 
duction of colored copperplates, eight in number, from Bell, 
and upwards of two hundred wood-cuts, selected from vari- 
ous authors. The latter are executed in superior style, as are 
all other portions of the work. In truth, of the many re- 
prints that have come under our notice, this is by far the 
most beautiful in appearance. It cannot fail we should think 
to be received with equal favor as the former editions. C. 



Selections from American unti iForeCfln Journals. 



On a Variety of False Aneurism. By Robert Liston, F. 
R. S. Read to the Royal Medical Chirurgical Society, March, 
1842. — Mr. Liston having stated, in his introductory observa- 
tions, that he has met with a remarkable instance of disease, 
and that much benefit is likely to result from the detail of un- 
successful cases, narrates the case, first published in The Lan- 
cet, of which the following is a summary: 

"A boy, nine years of age, about two months back, after an 
attack of cough and fever, became the subject of a swelling 
below the right ear, which was fomented and poulticed. The 
tumour slowly increased, but a few days before his admission 
into the hospital it began to progress rapidly. My projecting 
into the fauces it impeded respiration and deglutition, and it 
pointed near to the posterior border' of the sterno-mastoid 
muscle. An obscure fluctuation was perceived by the touch, 
and some degree of pulsation in the course of the carotid 
artery." 

Let the unprejudiced reader review this evidence, and state 
the nature of the case from the symptoms. Would he believe 
it to be one of aneuiism? We ought not to credit that he 
did, were he to answer in the afiirmative. Does he recollect 
the rarity of aneurism in a child? Did he ever hear of caro- 
tid aneurism in a child? Does it accord with the history of 
aneurism, that aneurism should appear and become developed, 
almost to bursting in two months? It is not usual to find the 
artery, in a case of true aneurism, passing over the superfi- 
cial aspect of the tumour. The reverse of that is always the 
fact. Moreover, is it likely that an aneurism of the common 
carotid would acuminate behind the posterior border of the 
sterno-mastoid muscle? Every well educated surgeon must 
reply in the negative. 

Mr. Liston regarded this tumour as an abscess, and intro- 



284 



On a Variety of False Aneurism. 



duced into it a bistoury, when out spurted a jet of arterial 
blood. The opening was secured, and on the following day 
the carotid artery was tied. In other words that treatment 
was adopted which would have been followed had the true 
natures of the tumour been detected at first. On the thir- 
teenth day after the operation, secondary haemorrhage from 
the seat of the ligature ensued. This was repeated on the 
fifteenth and sixteenth, and on the latter day the boy died. 
This treatment was accordant with sound practical surgery; 
and, now, what was the result of the post-mortem examina- 
tion? A verification of the diagnosis of Mr. Liston. There 
was no disease or dilatation of the arteries, but on the poste- 
rior aspect of the common carotid, just at its bifurcation, a 
circular aperture was found, communicating with a cyst of 
condensed cellular tissue, lined by a pyogenic membrane, 
identical with the ordinary structure of the cyst of an 
abscess. The coats of the artery were seen to terminate 
abruptly at the edge of the o|)ening, and there was no coagu- 
lum in the sac. This certainly was not a case of ordinary 
aneurism, but an instance of a rare surgical affection, an ab- 
scess communicating by ulceration with an artery, and thus 
giving rise to a "variety of false aneurism." The abscess had 
formed behind the artery, raising the latter from its bed, and 
separating its connections, so as to deprive it of its share of 
nutrient vessels. In this state of the vessel ulceration was a 
natural consequence; an aperture was formed, and the cyst 
of the abscess, previously small, became rapidly distended. 
We do not dwell on any question relative to the non-appear- 
ance of pus, either in the jet or after death. Who could dis- 
tinguish pus, probably a small quantity, in a jet of arterial 
blood, or in arterial blood occupying a cyst of large size? 

Having cariied the matter to this point of the inquiry, we 
express here our opinion that Mr. Liston has conferred a ben- 
efit on medical science by recording the history of this vari- 
ety. The paper is accompanic<l by tiuht cases which Mr. 
Liston considers to be of an analogous kind, and as proving 
the liability of the human system to such occurrences, and 
awakening attention to this additional means of forming a 
perfect diagnosis under similar circumstances, leading to the 
most judicious mode of treatment. 

The first of the cases appended occurred to Dr. Craigie. It 
consisted in an extensive abscess of the tonsil, running down 
the sheath of the carotid vessels, and communicating with the 
common carotid, close to its bifurcation. 

In the third case the femoral artery was opened, by slough- 



A Submarine Thermometer. 



285 



ing, into a deep-seated abscess. The fourth case fell under 
the observation of Sir Aslley Cooper. 

In the fitlh case, recorded by Mr. Syme, the affected artery 
was the poph'teuh In the sixth, Mr. GulHver's case, the caro- 
tid opened into a pharyngeal abscess. In the seventh, Mr. 
Fergusson's, the lingual artery communicated with an abscess 
in the neck; and in the eighth tlie opening existed in the arch 
of the aorta. The latter case is narrated by Breschet, and 
evinces much judgment and philosophy in its details. 

"'It seems to prove,' says the writer, 'that medical science 
is thickly studded with difficulties, both as relates to diagnosis 
and treatment. It is to be remarked that sanguineous tumours, 
communicating, by a very small opening, with the interior of 
an artery, evince no pulsations in the early periods of the 
disease, when placed deeply among the tissues; and that, even 
in the latter stages, the movement is less a pulsation than a 
vibration, or trembling. Tliis fact is deserving of attention, 
inasmuch as it may be the means of enabling surgeons to 
judge, a priori, whether the disease is a sanguineous tumour, 
produced by the dilatation of an artery, or by the erosion of a 
part of the parietes of the arterial canal.' " — Lond. Lancet. 



A Submarine Thermometer. — This is a French invention of 
the celebrated Mons. Clement, which has been tried lately in 
England in pi'esence of the Lords of the Admiralty, on board 
the Lightning (steam vessel) Lieutenant Commander G. Snell. 
In relation to this new invention, we find the following in a 
late London paper. 

It appears from the thermometrical observations of many 
scientific navigators, that in seas of unfathomable depth the 
water is not so cold as over the banks, and that over banks 
near the shore it is less cold than over those at a greater dis- 
tance, but colder than in the sea. In experiments which have 
been made on the coast of Fiance with this submarine ther- 
mometer results have been obtained which fully establish the 
great service which this instrument may render to navigation, 
by furnishing a sure and constant indication of all sudden 
changes from deep to shallow water. It is evident also that 
it will serve to point out the proximity of vessels to icebergs 
which at certain seasons of the year render the navigation of 
the Atlantic attended with danger. This test could not, of 
course, be made in the experiments with the Lightning, but 
the other important qualities are correctly ascertained. Clem- 



2S6 



The Salts of Quinia. — Glass in the Body. 



exit's thermometer is kept constantly underwater at the same 
depth, and indicates the different temperatures of the water 
by means of a dial placed on the deck of the vessel, and 
always open to examination. The immediate action is com- 
municated by wheels, the working of which turns two hands 
upon the dial, the one marking the single degrees, and the 
other the tens. The whole is enclosed in a tube, and attached 
to the side of the vessel. 

The same gentlema, Clement, is also the inventor of two 
instruments that have been well tested in France and Eng- 
land, to ascertain the speed of steam vessels, and to deter- 
mine the heat of water in their boilers. The first is named a 
Siilometev, a title given to a substitute for the common log; 
and the second is termed the Steam Engine Indicator. The 
three instruments are described as being inventions of great 
practical value. 



The Salts of Quinia. — Prince Lucien Bonaparte has been 
making further researches on these medicinal agents. We 
have already once alluded to his experiments. He now re- 
commends the employment in practice of both lactate and 
valerianate of quinia in preference to the sulphate, the latter 
not producing those functional derangements in the nervous 
system which the sulphate sometimes causes; and the former 
on account both of its greater solubility and more energetic 
action. The fact, established by various physicians in the 
Roman Maremme, that quinia alone, or its hydrate, is more 
efficacious as a remedy for intermittents than the sulphate, 
the prince considers due to its being converted into a lactate 
by the lactic acid of the gastric juice. This opportunity may 
be taken to mention (see Gaz. des Ilopitaux) that attempts 
have been made to combine quinia with ferrocyanic acid, and 
a substance entitled hydro-f erroc i/anale of quinine has crept 
into pretty extensive use among French practitioners. But 
Pelouze has ascertained that this substance is in reality noth- 
ing more than quinine mechanically mixed with a little Prus- 
sian blue, the consequence of spontaneous decomposition of 
the acid. — London Lancet, Jan. 28, 1843. 



Consequences of the Accidental Introduction of pieces of 
Glass into the Body. — Eck, of Berlin, reports in the "Medic. 
Zeitung," 1842, No. 32, that a Prussian subaltern officer was 



Introduction of pieces of Glass into the Body. 



287 



affected with a partial paralysis of the right arm, which had 
resisted all the general and local means of treatment employed 
for its removal. This paralysis, which chifly exhibited itself 
in the flexor muscles, had been preceded in its commencement 
by sharp pains, extending from the palmar surface of the 
thumb along the forearm and humerus. Eck examined the 
thumb on its palmar side, and on observing several old cica- 
trices there, he elicited from the patient that a few years pre- 
viously he had fallen down with a bottle in his hand, several 
fragments of which had penetrated his thumb; but, as he had 
been assured, every one of these was afterwards extracted. 
Eck, however, rationally conceiving that some fragment might 
still remain to keep up the present symptoms, pressed each of 
the cicatrices with some force, which operation in one place 
caused acute pain. He accordingly made a deep incision in 
that place, and on probing it with the end of a bistoury he 
found his instrument distinctly to strike against a hard and 
gritty substance. After the haemorrhage had been in some 
degree assuaged, Eck, who now made out clearly that this 
substance was a piece of glass, extracted it by the help of a 
pair of forceps, dressed with charpie; but with considerable 
difficulty, so deeply was it imbedded, and closely enveloped 
with the surrounding structures. It proved to be about half 
an inch in length, and of a curvilinear shape, its larger ex- 
tremity having been the more deeply seated. On its remo- 
val the patient soon recovered the complete use of his arm. 

In the "Gazette des Hopitaux" for tlie 22d Dec. ult., is de- 
tailed the case of a man who having severely cut himself by 
treading on some broken glass in his bedroom, entered the 
Hotel Dieu, Paris, where his wound was healed, the continu- 
ance of a piece of glass, deeply seated within it, not being 
recognised; but about five months afterwards he was unable 
from pain to put his foot to the ground, and he re-entered the 
hospital. Breschet, after ascertaining the fact that a foreign 
body still remained within the foot, made a crucial incision in 
the sole, and extracted a piece of glass, nearly an inch in 
length by half an inch in breadth, from the space between 
the first and second metatarsal bones. A severe attack of 
phlebitis supervened after the operation, as far upwards as the 
groin, and which was not overcome without much care, nor 
until the lapse of nearly a month, the patient being of a lym- 
phatico-nervous temperament. — Ibid, Jan. 21, 1843. 



8SS 



A Case of Diseased Ear. 



Report of a case of Diseased Ear.irhich produced death, 
in a child of four years of age. — By Thomas Carroll, M. 
D., of Cincinnati. — M. W., a female child, was admitted 
into the Orphan Asylum, at the age of two years, and at the 
time of admission was laboring under chronic diarrhoea, 
which had worn it down to the last degree that life could en- 
dure; and at the same time it had suppuration of the right 
ear. After being in the Asylum some months, its health be- 
came better; but the ear continued to run. and the abdomen 
enlarged to unusual size. Notwithstanding the improvement 
of the general health, the diarrhcea continued, and the ear 
gave no evidence that suppuration would cease, though the 
diarrhoea at times seemed to promise a total cessation, yet 
it returned and became more severe at short intervals, until 
death. The strength did not improve as was expected, at 
least as far as regarded the inferior extremities, which latter 
circumstance was probably owing to the want of care, in not 
making her use them in endeavoring to stand. The want 
of proper exercise of the lower extremities caused a great 
disproportion in size between them and the rest of the 
body. 

\\'hen I first enquired into the situation of this patient, 
which was in !March, 1S42, 1 found that she was fretful, and 
seemed to sufler pain, as she spent large portions of her 
nights in sitting up in her cradle and rocking herself con 
stantly for hours; and afterwards would sleep nluch through 
the day. 

As the ear ran very much, I directed a solution of the ni- 
trate of silver to be injected into it several limes a day, 
which was sometimes to be intermitted, and suds or warm 
water to be used in its place. Blisters were applied behind 
the ears, and her diet was rigidly regulated. For the de- 
rangement of the bowels one grain of Dover's powder, one 
of rhubarb, and half a grain of calomel, were combined and 
occasionally given. About a month before her death, a 
phlegmonous tumor appeared on the right hip, and suppura- 
ted, and discharged considerable matter. No sooner did 
this abscess heal, than the ear seemed more aggravated; the 
diarrhoea increased, and the whole side of the head became 
very much swollen; and the motory nerves on the side of the 
face lost their influence, showing that the portio dura of that 
side had become diseased. But. if motion, which had been 
given by this nerve, was lost; sensation, that in this part is 
derived from the fifth pair, was most acute. We are told by 
Sir C. Bell, tliat when a diseased condition, or rather de- 



A Case of Diseased Ear. 



289 



struction, of the expansion of the seventh pair of nerves on 
the face takes place, that the eye-lids of the affected side 
cannot be closed, as the orbicularis palpebrarum has its mo- 
tory influence from that source. Aside from this, the pres- 
ent case is a beautiful illustration of the principles of Bell, 
for the child had the power of shutting the eye on the affec- 
ted side. 

The matter discharged from the ear had long been offen- 
sive, and it was evident that caries of the petrous portion of 
the temporal bone had existed to some extent for many 
months, but now the evidences were more decided, as the 
cavity of the ear received a larger amount of fluid than usual; 
and from examination the tympanum appeared to be gone. 
Large amounts of pus of an ill-conditioned kind was con- 
stantly discharged. The inflammation became intense over 
the mastoid process, and anterior of the ear; and forty-eight 
hours before death mortification of the integuments over 
the mastoid process took place; a few hours after a similar 
condition resulted anterior to the ear; and at death the ear 
was nearly ready to drop off. Poultices alone seemed to 
give any relief. 

During the last few days the patient showed evident 
symptoms of great pain in the head; but at no time was 
there the least evidence of delirium, though much irritabil- 
ity of temper was evinced to the last moments of life. 

After death I examined the morbid appearances of the 
head, aided by Drs. AVoodward, Warder and Young. In ex- 
posing the cranium in the usual way, the cavity around the 
ear was laid open, and was found to contain considerable 
pus. The cavity extended over most of the squamous and 
petrous portions of the temporal bone, foUov. ed the zygomatic 
process nearly to the malar bone, and extended down the 
condyloid process of the maxillary bone to its connection 
with the angle of the jaw. The bones had lost their proper 
covering every where connected with the abscess; even the 
internal ear had nota vestage of any tissue covering the bone; 
and its inferior wall was perforated by caries about the eighth 
of an inch from the outer margin, which had been itself in a 
carious state for a considerable time. The foramen for the 
entrance of the internal carotid artery had thrown off its 
proper investment, and the artery meandered naked tlirough 
it. The portio dura was either totally or nearly destroyed at 
its exit. 

On the inner side of the temporal bone, and immediately 
at the entrance of the internal carotid, the dura mater wkI 
5 



290 



Encephalo-Spinal Meningitis. 



found inflamed, and separated from the bone. At the base 
of the cerebellum the arachnoid membrane was opaque, and 
the surface of the brain abnormally vascular. About two 
ounces of fluid escaped from the surface and ventricles when 
the brain was exposed. 

The pupils of the eye in this patient never dilated, and 
the eyes continued clear all the time — an instructive lesson 
with regard to the symptoms indicating effusion within the 
cranium. 

This patient died at the age of four years, and had been 
under my care from the middle of February, 1842, until Au- 
gust of the same year. I do not know that any treatment 
could have been instituted, at any time, that would have 
proved efficacious in the management of the case; it is most 
probable that nothing could have been done, unless at a very 
early period. I have no knowledge of the circumstance that 
led to the suppuration of the ear, nor do I know at what 
time of life it took place. — Western Lancet. 



Encephalo-Spinal Meningilis. — Dr. Bell, editor of the 
Bulletin of Medical Science, designates by this term, the dis-, 
ease described by Dr. Richardson, of Tenn., in the last vol. 
of this Journal (p. 430, Dec. 1842); and, after quoting Dr. 
R's account, gives the following notice of a discussion in 
the French Royal Academy of Medicine (sitting of the 6th 
September last) on a similar disease that prevailed in differ- 
ent parts of France. 

"The subject of the disease described by Dr. Richardson, 
was brought up in a meeting of the French Roj'al Academy 
of Medicine by a Report from M. Ferrus, on a memoir sent 
by M. Rollet, chief pliysician to the military hospital at Nan- 
cy. It is well known that the epidemic meningitis prevailed 
in dilTerent parts of France, viz: at Versailles, Bordeaux, 
Avignon, Strasburg, &c. Interesting accounts of the disease 
have already appeared, by Faure, Villars, Chaufl"ard, Forget, 
&.C. It showed itself in Nancy with most severity among 
the military. Rollet regards it under two aspects, and as 
constituting two varieties: cerebrospinal meningitis and en- 
cephalo-meningitis, according as the envelopes alone of the 
nervous centres, or the cerebral substance itself participate 
in the inflammation. At Nancy, as elsewhere, the disease 



Encephalo-Spinal Meningitis. 



291 



manifested itself by symptoms of great violence; tliere having 
been present the same disorder, in the meninges, active con- 
gestion, suppuration, and even softening of the brain and 
spinal marrovvT, according to the degree and intensity of the 
disease, as exliibited in post-morlem examinations of those 
who sank under it. The symptoms were, also, very much 
alike in different places in which the epidemic made its at- 
tacks, modified, liowever, by the seat of the inflammation; — 
a point on whiclr RoUet lays considerable stress. 

The subject of treatment is of course important, and it has 
been carried out according to the view of the pathology of 
the disease entertained by different practitioners. At Bordeaux, 
the disease having manifested some symptoms of periodicity, 
sulphate of quinine combined with opium was much thought 
of. At Avignon, Chauffard derived from opium, results de- 
scribed as truly miraculous. After some tentative practice, 
Rollet hit upon a plan which was successful, in his hands, 
but which he had recourse to only in cases of encephalo-me- 
ningitis. It is cauterization of tiie spine with red-hot iron. He 
used the cautery in such a manner as to give rise to a burn 
of the second degree, along the depression on each side of 
spinous process; repeating several times this energetic prac- 
tice. In most cases the sensibility which had been deadened 
was soon revived; the pulse recovered its force and fullness, 
and, in fine, reaction followed sufficient to allow of bleeding 
the patient, — with a frequency adapted to the indications of 
the case. In two patients, symptoms of intermission hav- 
ing appeared, sulphate of quinine was employed. One of 
these persons died; the other recovered. 

The following is a summary of the therapeutical course 
pursued by Rollet: — Fourteen cases of simple cerebro-spinal 
meningitis were treated with antiphlogistics alone; and 
of these all recovered. Of the same number of persons 
(14) attacked with encephalo-meningitis, four were subjec- 
ted to the ordinary treatment, all of whom perished. The 
other ten were treated by cauterisation, with a result of six 
cures and four deaths. 

The reporter to the Academy, Ferrus, eulogised the man- 
ner in which the subject had been treated by Rollet, and pro- 
posed in consequence a letter of thanks, the remission of 
his memoir to the committee of publication, and the inscrip- 
tion of his name on the list of candidates for corresponding 
membership. 

An animated discussion in the Academy followed the re- 
port, in which Rochoux, Castel, Honore, &c., took a part. 



292 



Galvanic Forceps. 



These gentlemen thought that Rollet had committed an error 
in diagnosis. The extreme gravity and indeed almost con- 
stant mortality from meningitis were well known; and how 
then explain this with the success in treatment as related? 
Probably, continue the objectors, the disease was a perni- 
cious (congestive) fever, the paroxysms of which run into 
each other so as to simulate a continued fever. Some cases 
of rheumatism were also confounded with the reigning mala- 
dy. Bousquet, in proof of the epidemic not being an open, 
ordinary phlegmasia, referred to the success which Chauffard 
had with the employment of opium. In fact, this physician, 
alarmed at the results of a simple antiphlogistic treatment, 
went over, once more, a study of all the phenomena of the 
disease, and detected a predominance of disorder of the ner- 
vous system which called for the use of narcotics. 

To all these critiques Ferrus replies, by asserting that there 
was no mistake in the diagnosis. Rollet, as well as Forget, 
and a number of other distinguished observers in the depart- 
ments, did indeed at first suppose the existence of a perni- 
cious fever; but all of them, after an attentive and conscien- 
tious investigation, were led to form an opposite opinion. 
Now, when a number of enlightened men agree, without pri- 
or concert, in the same opinion, there are strong grounds for 
our admitting that their view is the true one. The number 
of cures is objected to in connexion with the nature of the 
disease dcsciibod; but the numbers furnished by Rollet are 
well authenticated, and are proved by proper documents duly 
detailed. But, besides, — ought we to compare that which 
passes in one locality, or during an epidemic, with that 
which transpires in another locality, and when the disease is 
sporadic? And, again, Baudelocque remarked, that what 
was said of the almost uniform mortality of meningitis, ap- 
plies to the granular kind in children and not to the simple 
meningitis of adults. The conclusions of the report were 
adopted by the Academy. 



Galvanic Forceps. — These forceps are made by Gorck, 
the instrument maker, by order of Dr. Kilian, only to see 
what might be flieir effect upon the uterus. The blades are 
made of co]iper and zinc, and the rnclals are properly isola- 
ted from the hand of the accoucher. The first experiment 
with the galvanic forceps was made upon a woman aged 27, 
of dry constitution, choleric temperament, and jaundiced 



Nursery Treatment of Infants. 



293 



complexion. The application of the forceps was decidedly 
indicated in this case. The head of the child, which was in 
the first position, remained fixed at the lower aperture of the 
pelvis; and the torpidity of the uterus was so great, that the 
child had not moved for two hours and a half; while the in- 
filtration of the scalp was of the size of a man's fist. Be- 
fore applying the forceps, Dr. Kilian had the patient bled to 
fourteen ounces; but this had no influence on the action of 
the uterus. The blades were easily introduced into the ute- 
rus; but the moment they were joined, the woman had a 
fresh pains which was very violent, without being unbearable. 
At the same time a movement was felt in the whole uterus, 
which became as hard as a stone, and lost the morbid sensi- 
bility which it had shown before on each examination. 

This state of things continued from the beginning to the 
end of the application of the forceps, and in spite of the 
hardness of the uterus the pains liad no expulsive power. 
Nothing, however, indicated any spasm of the internal sex- 
ual system. After four actions with the forceps, the head 
cleared the lower aperture of the pelvis, and then (as well 
as before), the femoral muscles underwent a spasm and 
trembling of an unprecedented kind. Dr. Kilian then re- 
moved his hands from the instrument, to see if the uterus, 
which was still contracted, would not complete the expulsion 
of the child's head; but this was not the case, so that he was 
obliged to continue the use of the forceps. 

The infant immediately breathed, which was surprising, 
when we consider how long it had been fixed in the lower 
aperture of the pelvis. Hardly were the shoulders free, when 
the child, which was very strong, began to cry, and the pul- 
sation of the cord immediately ceased. The uterus then 
contracted, and in five minutes the placenta was in the va- 
gina. There were no pains after delivery, and the lying-in 
was quite regular. 

N. Y. Lancet from Gazelle des Hopitaux. 



Nursery trealmenl of Infants, suhmilled to Prince Albert. 
By Joshua Waddington, M. R. C. S., consulting Surgeon 
of the Royal Sea-Bathing Infantry. — No other kind of milk 
to be given to an infant in addition to the milk of the mother 
or wet-nurse. 

The less rocking the better. 

When asleep to be laid upon its right side. 



294 



Nursery Treatment of Infants. 



The best food is "Lcmann's biscuit-powder," soaked for 12 
hours in cold spring water, then boiled for half an hour, not 
simmered, or it will turn sour. Very little sugar to be added 
to the ibod, and then only at the time iDhen given. 

Sweets of every kind, are most injurious, producing acid- 
ity, flatulency, and indigestion, sores in the mouth, and dis- 
ordered secretions. 

An infant will take medicine the more readily if made 
lukewarm in a cup placed in hot-water, adding a very little 
sugar when lahcn. 

The warm-bath (at ninety-four degrees of heat, not less, 
for ten minutes, every other night) is a valuable remedy in 
many cases of habitual sickness or constipation. 

"Soothing syrup," sedatives, and anodynes, of every kind, 
are most prejudicial. They stop the secretions. A very 
small dose of laudanum given to an infant may produce co- 
ma and death. 

When an infant is weaned, which is generally advisable at 
the age of nine months, it is of the utmost importance that it 
be fed with the milk of one cow, and one only, (a milch- 
cow), mixed with "Lemann's biscuit powder" (prepared as 
before directed) and very lillle sugar. 

Boiled bread-pudding forms a light and nutritious din- 
ner, made with stale bread, hot milk, an egg, and very little 
sugar. 

When an infant is twelve months of age, bread and milk 
should be given every night and morning: stale bread toasted, 
soaked in a little hot-water, and ihen the milk (of one cow) 
added cold. 

Solid meat is not generally required until an infant is fif- 
teen months of age, and then to be given sparingly, and cut 
very fine. Roasted mutton, or broiled mutton-chop (with- 
out fat), is the best meat; next to that, tender lean beef or 
lamb; then fowl, which is better than chicken; no pork 
or veal; no pastry; no cheese; Ike less bailer Ihe heller. 

An infant should not be put upon its feet soon, especially 
while leething, or indisposed. 

Avoid overfeeding at all times, more particularly when 
teelhing. It is very likely to ])roducc indigestion and disor- 
dered secretions, the usual primary canses of convulsions, 
various eruptive complaints, and inflammatory afl^ections of 
the head, throat, and chest. 

London Lancet, December 24, 1842. 



New Process for Anatomical Injections. 



295 



New Process for Anatomical Injections. — In a letter addressed 
to the Academy of Sciences, Paris, July 11, 1841, Doyere 
gives the following account: — I have employed, for nearly two 
years, a very simple process for obtaining fine injections. 
This process, which I believe likely to render some service to 
the anatomy of structure, and probably also to pathological 
anatomy, essentially consists in causing to enter in the same 
vessels, within a certain interval of time, two finely filtered 
saline solutions, which, by double decomposition, give an 
abundant and opaque precipitate. This succession of two in- 
jections is that which distinguishes my process from many 
others tried without success to obtain the injection of the 
capillary system by the same principle. I inject the second 
solution, as soon as the first has passed from the arterial sys- 
tem into the venous and lymphatic systems. 

I have tried on animals a great number of insoluble salts, 
with a view to determine those which would give the most 
satisfactory results, I prefer to all others 'the chromate of 
lead. I first inject the chromate of potass, and am convinced 
that the order of injection is a point not to be neglected. A 
blue colour may be obtained by the precipitation of Prussian 
blue; brilliant red by iodide of mercury; white by the car- 
bonate or sulphate of lead. The first has better succeeded 
with me than the carbonates and sulphates of lime and 
baryta. 

The advantages which this process appears to me to pos- 
sess over those in use, are above all to shorten the process of 
making fine injections, and to supersede any other prepara- 
tion. It may be used with equal advantage cold or hot, in 
general or partial injection; the materials employed are unal- 
terable, and may be consequently always ready. I will add, 
that the most minute injections required only a pressure which 
was evidently less than that of the heart's action. Poiseuille, 
to whom I made the process known several months since, in 
order that he might make use of it in his particular researches, 
has constructed an instrumcnt^by the assistance of which he 
can inject either liquid with that degree of pressure he con- 
siders proper. 

By the assistance of this process, I have more than once 
succeeded in injecting by the femoral artery in a single ope- 
ration, and in a few minutes, the capillaries of the muscular 
system in an entire animal, the adipose and cellular systems 
of the white and gray matter of the brain, of the conjunc- 
tiva, of all the mucous membranes, intestinal villosities, &c. 
The capillaries thus injected by the chromate of lead are 



296 



Syphilitic Retraction of the Muscles. 



more filled, especially after drying, than by the injections of 
size, but less than by those of varnish (verm's); there also re- 
mains some doubt in my mind relative to the actual diameter 
of the latter canals. Those which run parallel to each primi- 
tive muscular fasciculus, to the number of four or six, appeared 
to me to possess, in the dog, :^l-^{h or of a millimetre; but it 
is possible that their dimensions had been reduced by the 
action of one or the other of the two solutions employed, or 
that they had not been sufficiently filled. I am now engaged 
in determining the relation which exists between the size of 
injected vessels, and their size during life. — Microscopic Jour- 
nal from Comptes liendus, July 1S41. 



Syphilitic Retraction of thf. Muscles. — This is a disease of 
rare occurrence, and wliich has only of late received atten- 
tion. It aflects most frequently the ilexor muscles of the fore- 
arm, if we may be allowed to form an opinion from the gene- 
rality of cases observed at the venereal hospital, under 
Ricord. The three patients who presented this remarkable 
affection had arrived at that point of constitutional infec- 
tion characterized by the symptoms which are denominated 
tertiary by Ricord. fn all these the retraction was very simi- 
lar; the flexors of the fore arm being alFected by it. The mus- 
cles appeared shortened, as a result of the permanent con- 
traction, which did not permit the extension of the fore-arm; 
but their tissue, though firm, presented no appreciable altera- 
tion. An important symptom was the peculiar pain which 
existed in the contracted part; this pain was increased at 
night, and resembled closely that experienced in syphilitic 
aflections of the bones. In one of the patients the retraction 
was cotemporary with tertiary ulcerations of the throat; in 
another, with periostitis of the tibia. These patients were 
submitted to the treatment of iodide of potassium. The sun- 
cess, under its influence, was as prompt and easily obtained 
as in other tertiary symptoms. The pains ceased in each one 
as soon as the fifth or sixth day. The movements of the 
limbs underwent a progressive amelioration, and were soon 
perfectly restored. — Lond. Med. Gaz., July, 1842, from Bull, 
de Thcrapeut. 



Lead Colic. — Robertson on Caries of Ihe Teeth. 297 



Prevention of Lead Colic. — Mr. Benson, the managing 
director at the British white lead vvorlis, Birmingham, says 
that the use of wiuit he calls sulphuric beer by the workmen 
is an eflectual preventive of the colic arising Irom the elfects 
of the lead, and which, previously to the employment of the 
sulphuric beer, was exceedingly prevalent among the men. 
He was induced to try it from a statement made some time 
since, that sulphuric lemonade had been successfully used at a 
white-lead manufactorj' in France. Its action must be eject- 
ed by the chemical transformation of the poisonous carbonrvte 
into the innocuous sulphate of lead. The formula for the 
preparation of the beer is as follows; — Take of treacle, fil'teeu 
pounds; bruised ginger, half a pound; water, twelve gallons 
yeast, one quart; bicarbonate of soda, one ounce and a half 
sulphuric acid, one ounce and a half by weight. Boil the 
ginger in two gallons of water; add the treacle and the re- 
mainder of the water hot. When nearly cold, transfer it to 
a cask, add the yeast, to cause fermentation. When this has 
nearly ceased, add the sulphuric acid, previou>ly diluted with 
eight times its quantity of water, and then the bicarbonate of 
soda, dissolved in a quart of water. Close up the cask, and 
in three or four days the beer will be fit for use. As acetous 
fermentation speedily takes place, particularly in hot weather, 
new supplies should be prepared as required. The object in 
adding the bicarbonate of soda is to give a pleasant briskness 
to the beverage. The sulphuric acid remains greatly in 
excess. — Lancet, Dec. 17, 1843. 



Robertson on ihe Cause of Caries of the Teeth. — Prior to 
the appearance of the first edition of Mr. Robertson's trea- 
tise, in 1835, the prevailing opinions concerning caries of the 
teeth were those of Fox and Bell; the former maintaining 
that the disease consists in an inflammation of the bony sub- 
stance of the crown of a tooth, which se(;ondarily allects the 
lining membrane of the organ, causing its separation, and a 
consequent decomposition of the solid parts; the latter insis- 
ting that caries commences in inflammation of the bone im- 
mediately under the enamel, from which, he says, the tooth, 
owing to its imperfect vitalizalion, cannot recover, and death 
and decay arc the consequence. 

Mr. Robertson, on the other hand, maintains that the re- 
mote cause of destruction of the teeth is the decomposition of 
food which lodges in the interstices between them. 



29S Robertson on the Cause of Caries of the Teeth. 



The inflammatory theory, then, is to the effect that the 
teeth decompose by vital action, commencing in their inte- 
rior, and proceeding to their surface. Our author's theory is 
exactly the opposite, namely, that decay begins by chemical 
action upon the surfaces of the teeth, and proceeds to their 
interior, and that inflammation is the consequence, and not 
the cause, of caries. His arguments are chiefly derived from 
the fact, that the teeth decay only in such situations as are 
favorable for the lodgment and decomposition of food, and 
never upon their smooth and even surfaces; from their decay- 
ing in pairs, and at particular periods of life; from the ready 
relief which filling and filing aflbrd, if decay be not too far 
advanced; from the disease commencing externally and pro- 
ceeding inwards, and never conversely; and from the circum- 
stance, that artificial teeth are liable to the same species of 
destruction as natural ones. 

These arguments we apprehend to be perfectly sound, and 
in accordance with the rules of common sense and experi- 
ence; for we cannot imagine a disease, which owes its origin 
and progress to inflammation, to be susceptible of alteration 
or cure by means which, of all others, are most calculated to 
contribute to such action. But when the cause is purely 
chemical, and owing primarily to a defect of structure, it is 
not irrational to suppose that mechanical treatment will arrest 
or remedy it. It is on this ground that we think the practi- 
cal application of Mr. Robertson's theory particularly valua- 
ble. Believing, as he does, that inflammation is not the cause 
of caries^ but the consequence of it, and dependent upon the 
influence of atmospheric and other agencies upon the lining 
membrane of a tooth, he urges the necessity of removing any 
decay that may be apparent, A^/'ore the occurrence of pain; for 
after its commencement there is little hope of permanent 
remedy. He insists upon the propriety of constantly using a 
tooth-brush, so that any particles of decomposing food may 
be removed; and of an occasional inspection of the teeth by 
a dentist, that any lurking decay may be arrested. He tells 
us that these suggestions have wrought a considerable change 
in his own practice — that people now apply to have caries 
arrested, rather than to have teeth removed in consequence of 
^its ravages; and he maintains that, if this plan were univer- 
sally acted upon, tooth-ache would be comparatively unknown, 
and the organs would be preserved in beauty and usefulness 
to the remotest period of life. — Med. Ex., from London Med. 
Gaz., Dec. 9, 1842. 



Potassium in Atonic Ulcers. — Topography of La Plata. 299 



Iodide of Potassium in Atonic Ulcers. — The utility of the 
hydriodate of potass in secondary syphilis is pretty generally 
acknowledged. Lisfranc has employed it with success in 
ulcers of long standing, which have resisted other modes of 
treatment. A man, sixty-eight years of age, was admitted 
under his care at the Hopital de la Pitie, who had for eight 
years had two obstinate atonic ulcers on his left leg: one of 
which, five inches in length, extended round the limb for 
more than half of its circumference; the other was about two 
inches in diameter. The only topical application used was 
simple cerate and charpie, but Lisfranc prescribed a scruple 
of the iodide of potassium daily, which quantity he subse- 
quently increased to six grains every six hours. At the end 
of six weeks the health of the patient had become greatly 
improved; his flesh generally had acquired firmness; his face 
was ruddy; and he had even gained fat. The smaller of the 
two ulcers had completely disappeared in twenty-tive days, 
and scarcely one-tenth of the larger ulcer remained to be 
healed. In two months the man left the hospital perfectly 
cured. — London Lancet, Jan. 7, 1S43. 



Medical Topography of La Plata. — We are indebted for the 
following account to a review in the Gazette des Hopitaux, of 
a pamphlet by Adolphus Brunei, surgeon-major to the cor- 
vette La Perle. It is entitled 'Topographical, meteorological, 
and medical observations made in Rio de la Plata, during the 
blockade of Buenos Ayres.' 

The Riode la Plata is a great mass of Avater lying between 
the 3-lth and 3Gth degree of south latitude, which after hav- 
ing received the Parana, the Paraguay, and the Rio-Salado, 
falls into the Atlantic. Two considerable towns, Buenos 
Ayres and Monte Video, the capitals of the Argentine and 
the Eastern Republics, are situated, one on its right, and the 
other on its left bank. Its shores are pleasantly situated, with 
a temperate climate, and a very fertile soil. The spring be- 
gins in September, the summer in December, and the autumn 
in March. During the author's stay, the greatest cold was 
4-rO of Reaumur,=4I° of Fahr; and the greatest heat 24° 
R.=S6 F. The most frequent winds are from the N., the 
N.E., and the S.E.; they blow with violence, often change, 
and produce sudden and frequent alterations in the tempera- 
ture and hygrometric state of the atmosphere. 



200 Medical Topography of La Plata. 



The people who inhabit these countries may be divided 
into four principal classes. 

First, the Creoles, sprung from the conquerors, to whom 
may be added all the Europeans and North Americans. Se- 
condly, the Negroes imported from the coast of Africa. 
Thirdly, the half-castes, formed by the intermixture of Euro- 
peans, natives, and negroes. Fourthly, the natives, who may 
be divided into two classes; those, namely, who have become 
civilized, and those who, resisting every attempt of the Span- 
iards to subjugate them, have preserved their independence. 

The Indians in tlie savage state inhabit the Pampas, and 
the deserts of the great Chaco; and they are divided into 
tribes of eighty or a hundred families, governed by a chief, 
who is generally elected. Since the importation of cattle, and 
particularly of horses, into America, those tribes are no lon- 
ger cannibals. These Indians are below the middle stature; 
their head is large, their nose short and flat, and their cheek- 
bones prominent. The projection of the chin is wide, and 
the chin itself is the only part of the face that has hair; their 
lips are thin, and their mouth furnished with splendid teeth, 
which are admirably regular, and remain uninjured to an 
advanced age. Their chest is broad and prominent, and their 
limbs well turned; their hands and feet small; their complex- 
ion of a pale copper color; their long black hair meets at the 
lop of the head, and they sometimes let it hang down; their 
hearing is very fine, and their sight piercing; their constitu- 
tion is robust, they are bold riders, and never go but on horse- 
back. They are distrustful, thievish, greedy, and cruel; drun- 
kenness is their ruling passion; they are naturally lazy, and 
oppress their women with work. Their chief nourishment 
consists of horse-flesli, which they eat almost raw, and when 
it has reached a certain degree of putrefaction; at other times 
they dry the meat, and reduce it to a powder, mix it with 
plenty of salt, and make it into a paste. They use maize as 
food, and also make a fermented drink from it. The coagu- 
lated blood of a colt, kneaded with maize Hour and salt, is 
one of their tit-bits. At present, the incursions of those sava- 
ges into the dillerent provinces of La Plata are less frequent 
than formerly; yet from time to time thej' plunder the farms 
and carry off the cattle. They make war with ferocit3s mas- 
sacreing the men, and sparing only the women, and some- 
times the children. 

This part of America is exempt from the morbid scourges 
which devastate other countries. The plague of the East, 
the yellow fever of the Antilles, the cholera, typhus, and 



The Chigoe, or Gigger. 301 



intermittent fevers, are not seen there. Among common dis- 
eases are catarrhs, sore throats, croup, hooping-cough, pleu 
risy, and pneumonin, all connected with the rapid variations 
of temperature. Phthisis is also very destructive there. Dis- 
eases of the skin are very frequent; small-pox, measles, and 
scarlatina, are dominant epidemics. Caries of the teeth is 
endemic, and appears very early; girls, in particular, of six- 
teen or seventeen, have none but decayed teeth. The rava- 
ges of small-pox are frightful, especially among the native 
savages, whole tribes of whom it has often destroyed. The 
slightest wound, and frequently the mere transition from heat 
to cold, is sufficient to produce immediate tetanus. The 
negroes and Europeans are more usually attacked by it than 
natives. The gauchos, or half-caste shepherds, often succeed 
in treating this terrific disease by wrapping the patient in a 
sheep-skin recently flayed. Hepatitis and dysentery are com- 
mon in the towns, and syphilitic diseases in the country. 
Goitre is endemic; and the negroes are subject to tubercular 
lepra. — New York Lancet. 



The Chigoe, or Gigger. By Frederick Roberts, M. D., 
Assistant Surgeon of the .'39th Regiment. — As medical authors 
give no account of the chigoe, which becomes so often para- 
sitic to man, and a source of considerable annoyance to him 
in the West Indies, and as it has further been doubted to be 
an insect, the following short paper, containing the slender 
information that could be gathered from a few examinations 
of cases, respecting the habits, effects on the body of man, 
and treatment for its removal, is offered. 

The "chigoe," or "chiego," of the West Indies, and the 
"pulex penetrans" of naturalists, consists of two species, the 
black and the white, in the natural history of which there 
appears to be no difference. The habitation of the "gigger," 
as it is likewise called, is in stables, kitchens, and on the 
ground in the open air in dry weather, which is the season it 
mostly prevails in — that is, from December to July. It 
attaches itself to the feet of those who walk about bare-footed, 
and those whose occupations are in kitchens, abounding in 
ashes and other filth. Holes in boots or shoes render one 
liable to be attacked by them. Its intrusions are not confined 
to the human species, but it is found to attach itself to cats, 
dogs, sheep, and still more to pigs. 

The parts of the body it is found in are the soles of the feet 



302 On Contusions of the Muscles. 



and toe?, and occasionally the fingers. It insinuates itself 
beneath the skin, and there deposits its eggs in a nidus of a 
tough gelatinous substance. Attention is first drawn to the 
presence of these insects by a gentle itching, which, as the 
insect insinuates itself deeper, and the nidus begins to grow, 
becomes, in a few days, less tolerable. The nidus, containing 
longish-shaped white gelatinous eggs, is a cyst of a tough mem- 
brane, and arrives sometimes to the size of a pea before the 
eggs are hatched, after which the new being likewise insinu- 
ates itself into the skin; so that in tho?e who neglect extract- 
ing them there are clusters, buried under the skin of the soles 
of the ieet and toes, which raise it in little round eminences, 
and create irritable sores, oozing a serous lluid,and ultimately 
intractable ulcers — nay, the entire toe has been known to be 
lost by the creeping ulceration that is established. The black 
gigger diifers so much in its effects from the white, to which, 
it lias been said, it otherwise resembh's, as to lie called the 
poisonous gigger, and produces much more malignant sores. 
The treatment for the removal of the chigoe consists in ex- 
traction by means of a needle — an operation dexterously per- 
formed by the negroes, and free from pain. — New York Lan- 
cet, from London Med. Gazette. 



On Contusions of Muscles. — By Wi>i. yVij.ison. — The most 
interesting circumstance connected with contusions of mus- 
cles is the dilhculty of distinguishing those injuries from dis- 
locations or fractures of those bones which form cups for joints. 
Muscles are bruised by falls or blows; a limb is consequently 
stifl' (whilst lenghtcned or shortened), and it becomes motion- 
less at a joint, so tlint neither flexion nor extension can be 
performed by the subject of the accident; and sometimes con- 
siderable swelling ensues before a medical man arrives. The 
surgeon's attempt to move the limb, in order to ascertain the 
nature of the injury, produces a painful spasmodic action of 
muscles, sometimes without proving advantageous to himself, 
in his endeavour to find out the precise cause of the loss of 
muscular action and the stilfncss of the limb. And whilst the 
surgeon has no means of completely satisfying himself with 
resy>ect to the accident, he is closely questioned by the patient 
and his friends, and must either express liis doubts or give 
indirect answers. We all know that by sleeping with the 
head upon the arm, so as to make good pressure on the me- 
dian nerve, we may become unable, during many minutes 



On Contusions of the Muscles. 



303 



after waking, to move the fore-arm; that by sleeping cross- 
legged in a chair, so as to make a firm pressure upon the pop- 
liteal nerve, we may be, during many minutes, unable to stand 
upon the leg; that rheumatic stitlhess may require great mus- 
cular elVorts to restore the use of the limbs: and that some- 
times after fractures of the arm or thigh, one means only can 
overcome the muscular rigidity, and restore action — namely, 
the frequent, resolute eflbrts of the patient to put the muscles 
in action; but I think it behoves us especially to ascertain the 
difTerent effects and the practical consequences of violent 
muscular contusions. 

1. The muscle or muscles may be so bruised as to be sim- 
ply benumbed (with tonic or permanent contraction or with 
relaxation), the nerves being alVected by the fall or blow, 
something like the brain from concussion. 

Cask I. — Mr. Smith, of this town, remained with his leg, 
for half an hour, under a horse which had fallen with him, 
and which had tiien laid upon him, the horse having made 
fruitless attempts to get up whilst the leg was under him. 
Mr. Smith could not move his leg when first lifted up; but, 
being supported, he made great ellbrts to use it, until in ten 
or fifteen minutes he gradually became able to walk. 

Case II. — A woman, nan\ed Parkin, of Ordsall, fell from a 
load of hay upon the hard ground, in a very hot, dry summer; 
her thigh was for some weeks in the exact position of a dislo- 
cation into the ischiatic notch. By forcible extension I could 
place the limb in the natural position without pain; but it 
always returned to the apparently dislocated position. No 
fracture of the acetabulum nor of the neck of the thigh-bone 
could be felt. In four or five weeks she recovered the use of 
the limb. 

2. The muscles may be bruised whilst in action, and remain 
stitT (with atonic contraction or with relaxation) so long as 
they are left at rest; but the moment an attempt is made by 
the patient or surgeon to move the limb, a violent, painful 
quivering or irregular spasmodic action comes on, and the 
limb cannot be placed in the natural position. 

Case III. — A boy was carrying two pails full of water sus- 
pended from his shoulders; in attempting to step down with 
them, from a very highly-raised causeway, he slipped back- 
wards and sideways upon the edge of the causeway, shooting 
his heels before him. On my arrival his leg presented the 
appearance of a dislocation upon the pubis. Every attempt 
to bring that knee to a level with the other, cither on a mat- 
trass or when standing upon the sound limb, failed; but it 



304 



On Contusions of the Muscles. 



produced painful, spasmodic muscular action. The chief pain 
was in the groin, where there was a swelling; but as the head 
of the thigh-bone could not be felt there, J proclaimed the 
accident to be "a serious injury of the muscles," which prob- 
ably would continue some weeks. By leeches, fomentations, 
&c., the boy recovered in a week. 

3. Muscles may be bruised, with extravasation or some 
injury ending in suppuration. 

Case IV. — I was called (July 1) to a lady who had been 
thrown out of a pony carriage in this town; her shoulder was 
dislocated, and her leg was bruised. Both before and after 
the dislocation was reduced she walked twenty or thirty yards 
very well, and she was sent home, a few miles ofi", in a chaise. 
The leg swelled, and became stiff and useless (to herself im- 
movable). After leeches, fomentations, poultices, &c., had 
been used, with entire rest for upwards of five weeks, she 
became alarmingly ill, with high constitutional disturbance 
during her seventh month of pregnancy; and in about a week 
from that time (on the 17th of August) I opened a deep-seated 
abscess under the fascia of the gastrocnemius muscle, after 
which she became perfectly well, before her confinement (on 
the 17lh of October), from which she recovered as usual. 

4. Muscles may be bruised, with laceration of fibres. 
Case V. — In June, 1839, I was desired to visit a stout, 

heavy, muscular man, who, it was supposed, had dislocated 
his hip. On my arrival I heard that, whilst sitting upon the 
shelvings of a cart, he fell backwards with his shoulders upon 
the wheel, and reached the ground (hard sand-rock) in about 
the sitting position. Moving the limb gave excruciating pain, 
and occasioned spasmodic muscular contraction; nevertheless, 
after having placed his shoulders and hips in a straight line 
upon a mattrass, and having grasped each ancle with one 
hand, 1 drew him downwards towards the bottom of the mat- 
trass, when I found the inner ancle-bone of the injured side 
full an inch and a quarter below the other, with the heel in- 
clining inwards. I could bend the knee upwards towards the 
abdomen, but could not cross one thigh over the other. Ad- 
duction could be efl^ected with some difficulty; but this limb 
was always longer than the other by an inch and a quarter, 
•with the knee separated, and the toes turned outwards when 
in the easiest position, and there was a constant pain in the 
perineum. If the case had been one of dislocation into the 
foramen ovale, I supposed adduction could not have been 
effected, and I was not aware that it could be any other vari- 
ety of dislocation. There was no crepitus about the joint; I 



On Co7itusions of the Muscles. 



305 



therefore believed it to be lengthening of the limb, mentioned 
by the late Sir A. P. Cooper, and delivered my opinion decis- 
ively, "that there was not any dislocation." However, I felt 
much more satisfied after my partner had accomi)anied me on 
my next visit. To the question, "What is the accident?" we 
replied, "a rupture of some part of tiie muscle which forms 
the buttock." 

The gentleman was bled in the arm. took an ojiiate, had his 
hip fomented, and warm, damp linen kept upon the painful 
part; he then took castor oil; on the Ibllovving morning twelve 
leeches were applied, and afterwards poultices. We cannot 
lift patients so atlected into and out of warm baths; he was 
kept in the easiest posture, tfcc, and the case went on quietly; 
but the lengthened state of the limb, the inability to move it 
without viulent pain lor some weeks, and the sensation of 
something in the perineum, gave rise to doubts amongst his 
friends respecting a dislocation. In this case extension of the 
rigid muscles after the second week, by pulleys applied as if 
for a dislocation into foramen ovale, until fainting was produ- 
ced, apfieared to be serviceable. The consequences oi" the 
accident were, not only that the limb gradually became of the 
same length as the other, but that contraction went on until 
it was about aji inch shorter, as it remains to this day, that he 
halts in walking, and that he cannot ride on horse-back with- 
out making the hip and thigh mus-cles very painful. 1 have 
on several occasions seen limbs as rigid from falls and bruises, 
when all attempts at motion have given violent pain; but in 
this case I cannot account for the lengthening and subsequent 
shortening of the limb, but by a laceration of muscular fibres. 
He can now walk ten or fifteen miles in a day without 
fatigue. 

Jn relating the foregoing cases, I may not have classed them 
correctly. For instance, the pregnant lady may have had 
some laceration of the deep-seated tissues of her leg, as the 
carriage wheel had evidently passed over it; but that being 
now doubtful, merely serves to show the ditliculty of stating 
the precise extent of injury at the first visit after an accident. 

A surgeon, called to reduce a dislocation, has to distinguish 
one from a Iraclure near the joint; and sometimes, in form- 
ing his diagnosis, he is perplexed by muscular rigidity; at 
other times by considerable tnniefaclion from extravasation 
of blood; and on some occasions by extreme tension from 
effusion, ihe conse(|uence of inflammation. As the late Sir 
A. P. Cooper, when speaking of dislocation, said, "Few acci- 
dents are more likely to endanger the reputation of the sur- 



3U6 



A Population gettivg Shorter. 



geon, as the patient may become a living memorial of his 
ignorance." I shall not apologize either for having called the 
attention of surgeons in the commencement of their career 
to this i)articular part of their practice; or for reminding 
them fui ther that the biceps tendon may be ruptured, or thai 
it may be displaced from its natural situation in passing over 
the head of the os humeri. — Amer. Journ., from Prov. Med 
Jour 71., May 28, 1842. 



We read the following article in the London Lancet, 
(Nov. 2G, 1812): 

A Population getting Shorter. — "In the department of 
Finisterre (Brittany), the use of ardent spirits seems to in- 
crease, and to be attended with some peculiar eflects on the 
population. In the two arrondissemcnts of Quimper and 
Quimpcrlc, the spirituous liquors imjxirted increased from 
1,869 hectolitres in 1825, to 3,985 in 1839, and, correspond- 
ing with this increase, the average stature of young persons 
subject to military service is said to have diminished until it 
had become 22 millimetres (about an inch) less in 1838 than 
in 1818. A much greater number of individuals was also 
found unfit for service in the former than in the latter named 
year. Gin and camomile have long been in repute in England 
for stunting the growth of little dogs." 

As a part of the general subject of Hygiene, and in con- 
nexion with the principles and practice which should govern 
and prevail in the temperance reform, we have had frequent 
occasion to correct the common, we might almost designate 
it vulgar, opinion of the temperance of the Frencli. as regards 
the use of alcoholic liquors, — because, forsooth, France is a 
country of vines and of wine manufactory. In reference to 
the very province nollccd in the above article, from the Lan- 
cet, we may refer our readers to a volume of ours published 
last year, "On Regimen and Longevity: Comprising Materia 
Alimcnlaria, Dietetic Usages, and the Influence of Civiliza- 
tion on Health and Duration of Life." pp. i2'>. 12mo. 

At page 78 of this work we find the following: "It will 
surpri.se many of my readers, who cannot connect ideas of 
interni)crancc in the use of strong drinks, with the habits of 
Frenchmen of any class, to be told, on very competent au- 
thority (Perrier, of Brest, Preface of Foreign Appendix to 
Report from Commissioners on the Poor Laws, p. G8), in 
reference to the people of Brittany: 'The principal cause of 



Abscess in the Walls of the Uterus. 



307 



misery is inebriety: its frequency among the lower orders 
keeps them in poverty. The "cabaret" (wine and brandy 
shops) absorb a great portion of their earnings. This vice is 
not confined to men; the women partake of it. It has de- 
creased within the last five years, but is still (1834) consider- 
able.' The favorable prospect held out in this last sentence 
does not, however, seem to have been realised. 

"I shall refer again to this dark feature of French dietetic 
regimen, in connexion with health, when 1 speak of grapes 
and their fermented juice or wine, and also in a subsequent 
chapter upon drinks. It will then be shown, by statistical 
documents of French preparation, that the people of France, 
in the use of wine, cider, beer, and brandy, for drink, con- 
sume in this way, per individual, more than the people of 
Great Britain and Ireland, per individual. The evils grow- 
ing out of the immense indulgence in alcoholic drinks, in the 
impoverishment, diseases, and demoralization of the French 
people, will also be exhibited, by reference to the communi- 
cations and reports of their own physicians, statists, and phi- 
lanthropists." p. 80.— Bulletin of Med. Science, Feb. 1843. 



Case of Abscess in the Walls of the Uterus, communica- 
ting with the Rectum. — Related at the Westminster Medical 
Society, December 3, 1842, by Dr. Frederic Bird. — Mrs. G., 
aged 37, had, previously to the last three years, enjoyed gene- 
ral good health, menstruating regularly. At this date she 
married, and was soon afterwards attacked with acute deep- 
seated pain in the hypogastric region, radiating to all parts of 
the pelvis, and increased by micturition and defecation. These 
symptoms were associated with general constitutional distur- 
bance, and. in fact, with all the ordinary symptoms of inflam- 
mation affecting the uterus. She passed through the usual 
forms of treatment, and altiiough the more urgent symptoms 
were mitigated, yet she continued to suffer during the three 
following months from occasional pain in the region of the 
uterus, always produced by attempts at expelling the contents 
of the bladder or rectum, the discharge of faxes being also 
sometimes effected with great difficulty. An internal exam- 
ination made at this period detected the uterus lower in the 
vagina than usual; there existed marked enlargement of that 
organ, the chief increase in size being found to occupy the 
posterior wall; the os and cervix uteri were painful to the 
touch and tumid. 



308 



Abscess in the Walls of the Uterus. 



Shortly after the'vaginal examination had been made, about 
half an ounce of pus suddenly escaped from the rectum, and 
she experienced immediate relief from her former symptoms. 
She now became the subject of diarrhoea, generally passing 
from six to eight evacuations daily, each of which contained 
more or less purulent matter; pain in micturition was no lon- 
ger felt, but she invariably sull'ered greatly when passing mo- 
tions. Tlie diarrhoea could not be arrested by any of the 
remedies employed; her general iiealth, nevertheless, slowly 
improved, and she went into the country, where she remain- 
ed during the succeeding two years, little or no variation in 
her symptoms having occurred. The diarrhoea, and with it 
the discharge of pus from the rectum, continued; on some 
occasions more than a pint of pus has been thus evacuated 
during twenty-four hours, and she observed that whenever 
the pus failed to be discharged so freely as usual the local pain 
became aggravated. During the whole of this period nien- 
struation liad been very irregular, generally occurring at in- 
tervals of eight or nine days, accompanied by much lumbar 
pain and the passage of coagula. 

After the lapse of the time nipntioned, she again applied to 
Dr. Bird, sutlei ing from nearly all her previous svmptonis, and, 
in addition to them, profuse menorrhiigia; the [)ain in the re- 
gion of the uterus was extremely acute, increased by the pas- 
sage of the faeces and by pressure on the lower p^art of the 
abdomen, to which became added a neuralgic condition of the 
genital organs, the slightest pressure upon whifh produced 
extreme suflering; so great was the pain thus excited that she 
was accustomed to employ a mechanical contrivance to pre- 
vent the bedclothes from touching the pubes. A vaginal ex- 
amination was, with much difficulty and pain, again made; 
the uterus was found to be nearly in the same state as before, 
excepting that it had become quite immoveable, appearing as 
if impacted in the pelvis, just as may be observed in some 
forms of malignant disease affecting that organ. No benefit 
resulted from medical treatment, occasional relief only being 
afforded by large doses of o[iium and the external application 
of belladonna. 

She continued to sufler from frequent discharges of blood 
from tlie vagina, and from all her former symptoms, until the 
lapse of six weeks, when she sank exhausted by the extreme 
suflering produced by her disease. 

A post-inortc.m examination was made twenty-four hours 
after death. On laying open the abdomen, the omentum, 
small intestines, and all the pelvic viscera, were found agglu- 



Abscess in the Walls of the Uterus. 



309 



tinated together by peritoneal adhesions of old date. On 
raising the uterus it was seen to be firmly attached by its 
upper and posterior portion to the rectum; it presented an 
irregular form, having tlie fundus enlarged to about thrice its 
natural size. A longitudinal section showed this enlargement 
to have been pi-oduced by an abscess seated in the substance 
of the wall of the fundus uteri, the cavity of which contained 
about an ounce of dark thick pus; the walls of the abscess 
varied in thickness from one to three-quarters of an inch, the 
thinnest portion being nearest to the cavity of the uterus. A 
communication by means of a short sinus could be traced 
from the cavity of the abscess to the adiierent portion of the 
rectum, and opening into that intestine by an aperture suf- 
ficiently large to admit of the passage of a thick probe, and 
evidently of old formation. No communication existed be- 
tween the uterine cavity and that of the abscess. The os and 
cervix presented no evidence of malignant disease. The Fal- 
lopian tubes and ovaries were adherent to the uterus, and 
could with difliculty be distinguished. The uterus had never 
been impregnated. 

He (Dr. B.) had been induced to bring the case before the 
notice of the society chieOy from the rarity of such forms of 
disease; very few cases had as yet been described, and those 
which he had hitherto met with in the works of Madam 
Boivin and others were complicated with carcinoma or other 
malignant disease of the uterus. In the instance he had rela- 
ted no evidence of such disease existed, but it was clearly a 
case of inflammation of the substance of the uterus termina- 
ting in the formation of abscess. It was difficult to account 
for the neuralgic state of the generative organs, unless the 
immoveable and apparently impacted condition of the uterus 
might be received as sufficient to produce such an effect by 
mechanically pressing upon the surrounding nerves, an idea 
favored by tlie fact that at the earlier period of the case, when 
the uterus was not thus fixed, the pain was limited to that 
viscus and did not extend to the external organs. 

*^* The preparation was exhibited to the society, where 
Dr. Chowne stated that he had never seen a similar case. The 
uterus and its appendages, he said, were in that conglome- 
rated stale which is usually observed in women who had led 
an irregular life, and which was, probably, in them, depend- 
ent upon early and excessive excitement. This adhesion of 
the ovaries. Fallopian tubes, &c., in prostitutes, had been no- 
ticed also in France. Perhaps, he added, in Dr. Bird's case, 
this condition might have been the result of the disease under 



310 



Tuberculous Disease of the Spinal Marrow. 



which the patient labored. On the same occasion another 
member of the society, Dr. Reid, said that he also was un- 
acquainted with the record of any similar case, excepting 
those related by Madame Boivin, and thought the disease 
must be a remarkably rare one. — Land. Lan., Jan. 28, 1843. 



Tuberculous Disease of the Spinal Marrow. — Dr. J. B. S. 
Jackson exhibited a specimen of the above disease. It was 
situated at the sixth cervical vertebra, and involved almost 
the entire substance of the organ at that part, forming an 
opaque, yellowish, solid, well-defined and uniform mass about 
as large as the tip of the little finger. The spinal marrow was 
somewhat enlarged at the seat of disease, and was a little sof- 
tened just above and below it, but was elsewhere quite healthy. 
The membranes, also, were healthy, excepf. for some thicken- 
ing of the dura mater at the upper part. In the brain there was 
a copious effusion of serum, with complete softening of the 
septum. Extensive tuberculous disease was found in both 
lungs and in the intestines, besides similar disease in the 
prostate gland and in the kidneys. 

The patient, an Irish laborer, set. 42, died September 
25th. Health quite good previously to the last year, and 
since then no local trouble except a disease in the ankle 
joint. The symptoms of spinal disease came on about three 
and a half months before death, and, when examined on the 
13th of August, were as follows: diminished sensation, with 
hardly a trace of voluntary motion in the lower extremities, 
the upper being very much less affected; very frequent and 
involuntary contractions of the right lower extremity, tending 
to draw the limb up into a strongly flexed position, and at- 
tended with very severe pain; some contractions of the left 
lower extremity, but without pain. Even on moving the bed 
clothes, the muscles of the lower extremities would be strong- 
ly excited, and, in attempting to straighten them when they 
were drawn up, his suffering was very great. In the upper 
extremities these spasms were very much less. The bladder 
was completely paralyzed, so that the catheter had been used 
daily for the last three weeks. These symptoms continued 
with but little change till death, the spasms being on one 
occasion so violent that the patient was fairly jerked out of 
bed, and fell upon the floor, though fortunately with but lit- 
tle injury. He suffered much also from a morbid sesibility, 
and from neuralgic pains in the right lower extremity, pass- 



Latent Insanity. 



311 



ing up into the abdomen. Respiration was carried on by 
the diaphragm, the intercostal muscles seeming to be com- 
pletely paralyzed. The catheter was used till the last month, 
after which the urine became involuntary; the dejections, al- 
so, were for the most part involuntary, whenever procured, 
the bowels being very costive. The spine was often exam- 
ined, but the patient scarcely ever allowed any pain or ten- 
derness there, neither was there any trouble in the head 
worth mentioning. When first seen his general aspect was 
sufficiently well, but as the disease advanced, he became ex- 
ceedingly emaciated, and for sometime before death was very 
much sunken, with sloughs about the sacrum. As to his 
pulmonary disease, he had no symptoms that led to a suspi- 
cion of it; these was occasionally some dyspnoea, but, as it 
was generally accompanied with a feeling as of a cord about 
the lower part of the chest, it was attributed to the paralysis; 
the nurse, on being questioned after the death of the patient, 
mentioned an occasional, very slight cough during the last 
few days, but never before. — Rep. of Bost. Soc. for Med. 
Improvement, Sept. 26th, 1842, in N. E. Quarterly. 



Latent Insanity. — In many cases the experienced eye of 
the medical practitioner may be able to detect the' existence 
of latent insanity. In such instances the patient evinces no 
evident indication of any irregularity of mind. His dearest 
friends and constant companions can perceive no alteration 
in manner sufficient to excite a suspicion of insanity. Oc- 
casionally the patient may manifest a strangeness and oddity 
of conduct, which is, however, but little noticed. The indi- 
vidual may, notwithstanding, be suffering from incipient 
symptoms of derangement. Me has not altogether lost all 
power of controlling his feelings or ideas; an internal strug- 
gle may be going on between what he knows to be a fact, 
and the false conceptions which almost like an avalanche are 
forcing themselves upon his mind. None but those who 
have gone through this dreadful ordeal can form an accurate 
notion of the mental agony which a person so unhappily 
situated experiences! Dr. Darwin relates the case of a most 
elegant lady who suddenly became melancholy. She retain- 
ed, however, so great a command over herself, that she was 
enabled to do the honors of her table with grace and appa- 
rent ease. After many days' entreaty, she informed her phy- 
sician that she thought her marrying her husband had made 



312 



Public Speaking. 



him unhappy (though it was a love-match on both sides), 
and that this idea she could not cfiace from her mind, day or 
night. It is astonishing for what a length of time a patient 
under such circumstances will struggle against a delusion 
which is endeavoring to fasten itself upon the mind. In 
such cases the patient gives no marked indication of mental 
unsoundness; she will attend to domestic duties, mix as usu- 
al with parties of pleasure, take her accustomed seat at the 
opera, and yet manifest no sign of the tempest raging within. 
How often do such patients confess to the medical practi- 
tioner, when tlie state of mind becomes so apparent as to 
compel the friends to summon relief, that for months they 
have been contending courageously against what they were 
conscious were erroneous perceptions. Hoping eventually 
to master these false ideas, they have concealed, from those 
in whom confidence ought to have been placed, their melan- 
choly condition. This state of mind is fraught with much 
cerebral mischief. It cannot exist for any length of time 
without serious consequences ensuing. 

j^. Winsloic's Health of Body and Mind. 



Public Speaking. — One of the greatest errors committed 
by public speakers, when addressing large bodies of people, 
is speaking too fast. They forget that distance has the same 
effect upon sounds as it has upon architectural or other orna- 
ments; it melts, as it were, the more minute parts into a 
confused mass. Elaborate and ornate passages in music 
cannot be appreciated by a moderately distant listener, while 
the bold and distinct slow movement can be felt and under- 
stood by him with ease. 



THE WESTERN JOURNAL. 



Vol. VIL— No. IV. 



LOUISVILLE, APRIL 1, 1 843. 



TRAVELLING EDITORIALS. 

Already do wc repent of our rash resolve, to take up, at stated 
periods, the pen editorial; and if said determination had not been 
made public, we should forthwith repeal it. Doubtless the 'public, 
that is our readers, would without much persuasion consent to such 
a repeal; but who is to move in the matter? One party is likely to 
be too proud — the other two courteous, and there the matter must 
rest. 

Removal of Dr. Barton to Cuba. 
Two days after our arrival in New Orleans, Dr. E. H. Barton, 
formerly a Professor in the Medical College of Louisiana, and lately 
President of the Board of Health of the City, (both of which estab- 
lishments he was mainly instrumental in effecting), departed for Ha- 
vana. If not intending to expatriate himself, this gentleman, from 
circumstances in the health of his family, may sojourn there for some 
years, during which, we trust, he will make a thorough investigation 
of its fitness for our invalids in the winter. Dr. Barton's long prac- 
tical acquaintance with the diseases of these climates, together with 
7 



314 



Travelling Editorials. 



his science and urbanity, must render him a valuable physician and 
friend to such of our invalids as may visit the island of Cuba. 
Winter ajid Spring visits of Invalids to New Orleans. 

It is difficult to understand why physicians will advise their pa- 
tiems with pulmonary disease to come into Louisiana in the winter, 
and early spring. Nothing in general could be more exceptionable. 
It is nearly a month since we entered the limits of this State, during 
which there have, it is true, been a few fair days, but with one excep. 
lion they were too cold for the valetudinary. The dampness of the 
atmosphere through the months of February and March, is so great 
as to render it injurious to all who labor under pulmonary disease: 
and the exposures on a winter voyage, are such as no invalid ought 
to suffer. They who seek a milder climate, should do so in Novem- 
ber, and continue in it till after the vernal equinox. 

Winter Temperature of the 3Iississippi. 

Tlie surface temperature of the Mississippi, from the mouth of the 
Oiiio to the Balize, we have found to be, during February, from 34' 
.to 44^ of Fah. Difference of latitude about 8° — general course of 
the river South. Thus a degree of latitude raises the heat of the 
river a degree and a quarter. But the effect is not wholly ascribable 
to change of climate, but likewise to change of altitude; though the 
influence of the latter must be less than that of the former, as it does 
not, probably, exceed two hundred and fifty feet; or about thirty feet 
to the degree of latitude. The discharge, for three months, of so 
great a volume of cold water into the Gulf, must exert an influence 
on its temperature, which might be ascertained by a sufficient num. 
ber of observations. We have as yet had opportunity to make a 
few only. In the "S.W. pass," beyond the bar, and within the geo. 
graphical limits oftheGulf, we found the turbid and saltlcss river-water 
to be 44°, while at the depth o( between fifty and sixty feet, where 
the water was nearly transparent, and decidedly salt, the heat was 
On one side of die fresh water, where the appearance was 
sumewhat turbid and the taste brackish, the heat was 53°, and a lit- 
tle beyond, in the green and salt water, it was 5G° and 57°. 
Medical College of Louisiana. 

We have made one visit to this Institution. Beginning its session 
later in autumn than the other .schools of the Union, on account of 
the occasional prevalence of yellow-fever in November, the lectures 



Medical Convention of Ohio. 



315 



continue through the month of March. We regret to say, however, 
that many of the pupils start home at the end of February. The 
number of the present session is, we understand, about thirty-five; 
which is an advance upon preceding years. They are principally 
from this State, Alabama, and Mississippi. The lectures are deliv- 
ered in a rented house, but the Professors have begun the creation of 
a fund for the erection of an appropriate edifice. Neither the State 
nor the city has done any thing for the Institution. Its Professors 
are seven in number, who deliver from four to five lectures daily. 
The opportunities for practical anatomy are ample. The tickets of 
the Professors are twenty dollars each. It must be admitted that this 
school, in the number of its pupils, has fallen short of the expecta- 
tions under which it was established; but we have not had an oppor- 
tunity of investigating the causes which have retarded its growth; and 
which, it is to be hoped, may ere long be removed. 

Death of Tiger.Tail. 

In two visits to the New Orleans' barracks the head quarters of 
Brig. Gen. -A.rbuckle, we saw the Seminole Chief Tiger-Tail, on a 
sick bed. We were surprised to find him capable of conversing 
with us, but were told that before the war commenced, he had spent 
a year in the family of Gov. Duval, of Florida. At the times of our 
visits the captive warriotp labored und^r a fever, with cough, and a 
leg more or less swollen and inflamed from accidental injury. By 
auscultating his naked and Aveather-beateh chest we heard, what per- 
haps but few had ever heard, the palpitations of his savage but patri- 
otic heart. Gen. Arbuckle, and the skilful surgeon of the post, Dr. 
Randall, were anxious that he should' receive the treatment which his 
case required; but he preferred his own physician, under whose in- 
cantations he expired a few days since. Since that time, his surren- 
dered countrymen have been sent on to Fort Gibson. 

New Orleans, March 10, 1843. I). 



MEDICAL COSVEXTIOX OF OHIO. 

We would remind tour readers that, according to adjournment, this 
body meets in Lancaster, Ohio, on the second ilonday in May — thf 
8ih day of the month. We anticipate an unusually interesting 
meeting, as at the last session, held in Cincinnati, and which wc 



316 



Louisville Medical Institute. 



had the pleasure of attending, many subjects of interest were referred 
to the coming one. 

We acknowledge the reception of the "Proceedings" of the fifth 
(last) session of the convention, which multiplied engagements have 
hitherto prevented us from noticing. We observe that it contains 
two papers, one "On the Topagraphy and Diseases of Scioto 
County, Ohio," by Dr. G. S. B. Hempstead of Portsmouth; the 
other "On the Causes and Treatment of Milk-sickness," by Dr. John 
Dawson, of Greene County. The rule adopted by the "Censors" 
(in the absence of any definite instructions from the convention) cut 
off all the other papers placed in their hands. This rule seems to us 
in the main correct, as also do the suggestions made by this committee 
in reference to the proper objects of attention on the part of members 
of the convention. A few such papers as that of Dr. Hempstead, 
would give the body a character abroad, which volumes of wire-drawn 
speculations on old and trite subjects would never create for it. We 
shall refer to this paper hereafter. C. 



ARTIFICIAL ANUS. 

We will not pay our readers the poor compliment to suppose that 
they have not read the learned and valuable**paper of Dr. Gross, on 
Wounds of the Intestines, which occupied so large a portion of the 
three previous numbers. They will, no doubt, be pleased to learn 
that we shall publish in the Journal for May or June, an article from 
the same pen on the nature and treatment of Artificial Amis. This 
will be in some sort an appendix to the paper just mentioned, and 
the two together will form one of the most complete monographs that 
we know. C. 



LOUISVILLE MEDICAL INSTITUTE. 

The published Catalogue of this Institution shows that there were 
one hundred and eighty-nine students in attendance during the past 
winter. Of these forty-six were from Kentucky, forty-six from Ten- 
nessee, twenty-eight from Mississippi, twenty-four from Alabama, 
thirteen from Ohio, twelve from Indiana, and the remainder from 
Louisiana, Georgia, the Carolinas, Virginia, Missouri, Illinois, Mich. 



"Meum and Team." 



317 



igan, (kc, &c. There were thiity-seven graduates. The Honorarj' de- 
gree of Doctor of Medicine Avas conferred upon the following gen- 
tlemen: JosiAH HiGGASON, Sonierville, Tennessee: Joseph M. 
Wood, Liberty, Missouri; Rcfus Havmokd, Brookville, Indiana. 
Joseph R. Buchanan, Kentucky . C. 



"MEUil AND TEUM."' 

Under the above head (which may or may not contain a typographi- 
cal error) the Medical Neivs, which seems to aspire to the respectable 
office of tender to the American Journal of the Medical Sciences, 
holds the following language: 

"Meum and Teum. — We observe that the editors of the Western 
Journal of Med. and S^irgery have done the editor of the American 
Journal of the Medical Sciences the honor to estimate several of the 
articles of his quarterly summary of sufficient value to be transferred 
to She pages of their Journal. They have considered the compli- 
ment of making use of his labours, however, sufficient, without think- 
ing it necessary to make the acknowledgment which bare justice re- 
quires in such a case." 

We freely acknowledge our indebtedness to the American Journal, 
as well as to other eastern periodicals, for foreign news, and the 
pages of this Journal will show that it has been our custom to make 
the usual "acknowledgment" — to a greater extent perhaps than some 
of our contemporaries, equally indebted as ourselves. There is 
scarcely a number of it that does not contain articles credited to the 
American Journal; and if such credit has been at any time impro. 
perly omitted, the editor of that Journal will, we are sure, do us ilie 
"justice" to believe that it was done inadvertently. We shall endea- 
vor to avoid such omission in future. 

The paragraph we have quoted strikes us as being tolerably ftrt, 
to come from one who, so far as we can see, has no interest whatever 
in the matter. It would be well for its author, perhaps, to polish 
both his manners and his Latin, ere he takes us to task again. We 
would also recommend him, in view of his disinterestedness on this 
occasion, posthac in res suas diligenter incumhere. We have couched 
this last in Latin, because, as he seems to have a fondness for the clas- 
sics, it. may thereby more readily attract his notice. Attention to 
thestj two suggestions may possibly keep him out of trouble. C. 



318 



Qiiadmppils of North .imerict. 



QUADRUPEDS OF NORTH AMERICA. 

John James Audubon, Esq., the distinguished author of the mag- 
nificent work on the birds of North America, is now engaged, in 
conjunction with his two sons, upon a similar work respecting the 
natural history of the viviparous quadrupeds of the same region. 
This work is already considerably advanced, having been in progress 
for several years. It is to consist of thirty numbers, several of which 
are already completed. Mr. Audubon recently passed through our 
city, accompanied by several scientific gentlemen, on his way to the 
Oregon Territory, where he expects to spend several months prose- 
cuting his researches. We had the pleasure of meeting him during 
his sojourn here. He was in fine health and spirits, his step as elas- 
tic as in youth, and his form still unbent and his eye undiramed by 
the suns and snows that have blanched his head. We were grati- 
fied with a view of some of the drawings for the forthcoming work, 
and were startled by the vivid and life-like portraits of some o^the 
more familiar quadrupeds. His pencil seems to have lost nothing of 
its wonderful power, and we can assure the lovers of science every 
where, that a rich treat is in preparation for them, such as Audubon 
alone could give. 

We cannot but look upon Mr. Audubon as one of the most re- 
markable men of the age. To our intellectual vision he stands soli- 
tary and alone. We are writing this paragraph almost in the midst 
of the scenes of his early labors, where, filled with the design of the 
great work which has made him world-renowned, he was struggling 
against mountain. difficulties that one of less bold and daring genius 
would have deemed insurmountable. Such they seemed to those 
around — and so utterly chimerical did his project appear that he had 
to encounter not merely the sneers and scofis of enemies, but the 
lukewarmness and the estrangement of friends. After long years of 
toil, of labors to which the fabled ones of Hercules were but as girl- 
ish pastimes, when he had well-nigh completed the vast undertaking 
that has rendered his name immortal, he was still regarded as one 
whom long sojourn amidst the unbroken solitudes of nature and in- 
frequent visits to the haunts of men had unsettled, and Avas considered 
a fit mark for rude gibes and jests. When at length he bore about 
him the splendid fruits of his martyr-like devotion, when the 
winged and beautiful inhabitants of our vast forests seemed flitting 



Anonymous Pamphleteers. 



319 



irom spray to spray upon his canvass, or pouring forth their "wood-notes 
wild" along his enchanting page, obstacles seemed to thicken between 
him and the darling object of his life. Men heard and wondered — 
few believed. To publish was deemed the ultima thule of temerity. 
"My friends told me," said he, "to burn up my drawings and go 
home. I Avent abroad and the same advice was given me, "burn up 
your drawings and go home." But upborne by the divinity within, 
and true to its unerring instincts, he pressed forward, with the same 
iron will, the same indomitable energy, and lo! his name has gone 
abroad upon every wind — absolutely identified with the natural his- 
tory of his native country! 

Such a man does not appear in every age — it takes centuries to 
give birth to him. His whole history is full of interest. Not 
that it is singular; for it is the history of most great men. Such are 
seldom if ever appreciated in their early career by those immediately 
contemporaneous, which stamps them at once as the true nobility. 
Genius with its keen, sky-cleaving pinion ever holds its flight 
high above that of the multitude, and with far gaze pierces the 
future. C. 



ANOiSYMOUS PAMPHLETEERS. 

The Editor of the Boston Medical and Surgical Journal (March 
15) speaks, in a tone of just indignation, of an anonymous pamphlet 
sent to him (from this city?) purporting to give "some account 
of the Faculty of the Louisville Medical Institute." He lashes 
its author or authors (for they are plural) to some purpose. Whether 
he has an inkling of whom he speaks, we do not know. He 
may rest assured, however, that he cannot say anything too severe 
of them. No epithets he could apply, would give any adequate idea 
of their cowardly meanness and malignity. Filihy and corrupt as they 
are, their sole gratification is in attempting to defile the good char- 
acter of others. As with obscene birds, this occasional belching-forth 
of the putrid contents of their stomach is necessary we suppose to 
their own safety — the only other effect it has, is to make them a 
stench in the nostrils of all good men, and thus widen the circle 
around themselves. The publication of this pamphlet, cowardly and 
assassin-like as it is in the extreme, could scarcely add to their dcgra- 



320 Medical Resignation. — New York Lancet. 



(lation, unless in that deptli there might be a lower deep. The fact 
that they are ashamed to acknowledge their own fiiiliy and leprous 
ofT-spring, might be taken as an evidence of some remnant of good 
in their depraved nature, if we did not know them to be us dastardly 
as they are dishonest, as bankrupt in moral courage as in all else. 

The secret of this matter can be told in a very few words. This 
pamphlet is composed of a number of scurrilous articles which ap- 
peared in one of the papers of this city, soon after the nefarious 
scheme to transfer tht; Medical Institute was defeated. These arti- 
cleswere concocted by the same knavisli Iriuinvirate who were so deeply 
engaged in that scheme, and wiio participated so actively in the publi- 
cation of the infamous report made to the City Council on the sub- 
ject. (See this Journal for September and October, 1842.) Of 
course, men who were base enough to sanction and give currency (as 
in that Report) to statements which ihnj knew to be false, would 
have no scruples about uttering stale and oft-repeated slanders, such 
as are contained in this precious pamphlet, with the addition of what- 
ever their own malice and devilish ingenuity could invent. What 
villainous act they will next be caught in, remains to be seen. C. 



MEDICAL RESIGNATION. 

Dr. N. WoECESTEK has resigned the chair of Physical Diagnosis 
and Pathological Anatomy in the Medical College of Ohio. We 
regret to learn that the state of his health rendered this step neces- 
sary. The trustees of the college, as we are informed, have since 
abolished tiio chair. C. 



NEW YOKK LANCET. 

The New York Lancet, which "blazed, the comet of a season," has 
comet-like "shot madly from its sphere" — in other words it is de- 
funct. "Wo could have better spared a" — worse journal. "The 
rage (if such there be) for hebdomadals will be short lived — " what 
think you of that now, O wise son of Ballymena! "Moon-struck" 
quoth-a? C. 



THE 



WESTERN JOURNAL 

O F 

MEDICINE AND SUEGERY. 



MAY, 1 843. 



Art. I. — Medical Topography of Central Arkansas; being 
Observations on the Locality, Climate, and Diseases of the 
City of Little Rock and vicinity, in the year 1840. By W. 
J. GouLDiNG, M. D., of Little Rock. 

The relative importance of Medical Topography to the ad- 
vancement of our science is now highly appreciated. Many 
elaborate papers of this kind annually appear in our jour- 
nals; and we are led to value these successive additions to 
our medical literature the more from the conviction that, if 
ever we have a digest worthy to serve as a guide to the 
practice of medicine in the Southern States, its best mate- 
rials will be sought in the accumulated contributions of local 
I 



322 Gould ing on the Medical Topography of Arkansas. 



medical history. Physicians, in innumerable dissertations 
on our science, have applied to all regions of the earth some 
aphorisms of Hippocrates applicable only to Greece and a few 
adjacent countries; this error is now known, and the most 
accurate observation of Nature in a given climate is found 
requisite to an enlightened and efficient practice in that 
climate. Nor is the studyof all the physical circumstances of 
a given district which may affect the health of its inhabitants, 
alone required; but the peculiarities which the same disease 
at different times assumes, are especially to be noted; and 
perhaps no country, from its great extent and varied natural 
features, calls more imperiously for the careful observation 
of these facts that the United States. But waiving further 
preliminaries, I proceed to the more immediate object of 
this paper. 

The city of Little Rock, which represents central Arkan- 
sas, is in latitude 34° 40', and longitude 15° 20', about 300 
•miles by water from the mouth of the Arkansas river where 
it joins the Mississippi. Major Long, who passed it in 1820 
says: "It is a village having six or eight houses and occu- 
pies a high bank of clay-slate on the south west side of the 
Arkansas river. Its site is elevated, and the country immedi- 
ately adjoining is in a great measure exempt from the ope- 
ration of those causes which produce a state of the atmos- 
phere unfavorable to health." It is in fact the first eligible 
site for a town that occurs in ascending this river; being 
near the centre, and the capital of a large and groM'ing state, 
its future destiny can hardly be mistaken. Besides a Uni- 
ted States' Arsenal, it has already many fine public and pri- 
vate buildings. Population, 2,400. 

The face of the country of central Arkansas, though much 
diversified, may be classed under three varieties; first, allu- 
vial or river bottom; second, upland or hilly; third, prairie. 

The first variety is chiefly met in descending the river; 
the soil is of the richest kind; it is the most thickly settled but the 
least healthy. It is here that the forest is seen in its greatest 
magnificence, where the cypress, oak and cotton-wood vie in 



Goulding on the Medical Topography of Arkansas. 323 



power, lending their support to enormous osier and grape- 
vines which delight 

"To weave their gorgeous tracery far above; 
With the light melting through their high arcades, 
As through a pillared cloister." 

But the want of good water, and the liability of this portion 
to the annual Nile-like floods of the Arkansas river, weigh 
against its great natural fertility. Yet the bottom lands of 
central Arkansas may fairly be set down as excellent of their 
kind; the banks rarely descend as they recede from the river: 
corn and cotton are the staple productions. 

The second, or upland variety, in the face of the country, 
is by far the most extensive; it is always rolling, often hil- 
ly, with but little undergrowth save luxuriant grasses and 
flowering herbage; having forest chiefly of oak interspersed 
with hickory, its whole aspect, so open, park-like, and beauti- 
ful, presents a striking contrast to that of the first variety. 
This second variety constitutes by far the most salubrious 
district; good springs of water are met with, but are not com- 
mon; corn and the small grains are grown advantageously, 
but cotton becomes an uncertain crop; most of the soil i.s til- 
lable, much of it decidedly good. 

The third variety, or prairie, is the least extensive, and i> 
found at a distance east of Litlle-Rock, between the Arkansas 
and White rivers; several small praries, and a large portion 
of "big prairie" so called, are found in this direction; usually 
of the better kind of dry or upland prairie, they easily admit 
of cultivation although as yet but little cultivated; their great- 
est drawback is the want of good water. 

From the foregoing it will be perceived that the greatest 
diversity in the face of the country obtains in central Arkan- 
sas; the sea-like prairie and the beetling cliff— the mountain 
torrent and the sluggish bayou — the sleeping lake and the 
mighty river, will not unfrequently by quick succession agreea- 
bly surprise the traveller or command the fullest admiration 
of the lover of nature. This marked diversity joined to a 
genial climate renders it a locality of peculiar interest in re- 



324 Goulding on the Medical Topography of Arkansas. 



gard to its natural productions; the muscadine and other wild 
grapes, as also the date-plum {dyospyros pubescens of Pursh), 
and the paw-paw (porcelia triloba), are found in perfection 
here. The cane (miegia) extends itself high up this river, 
and the beautiful china-tree is easily grown and is said to 
have become naturalised here; among the forest trees are 
found the false orange (maclura nurantica), evergreen holly 
{ilex opaca), tupello gum {liquidambra styracijiua), and the 
coffee-bean tree. Among medicinal plants, the palma christi, 
spigelia, two species gillenia and two baptisia, also the more 
valuable of the natural families labratae and solanae are here 
found in the greatest profusion; the tarantula, the scorpion, 
and centipede, (the last of enormous size) among reptiles; and 
beautiful specimens of the amethyst and topaz among mine- 
rals. Anthracite coal of an excellent quality is at this time an 
article of export from central Arkansas, and the locality of 
"Hot-Springs" in this State will yield to none in the world 
perhaps in geological interest. 

I come now to speak more particularly of the climate; in 
this respect we have a medium between that of New Orleans 
on the one hand and that of St. Louis on the other; it may 
also be observed that distance west of the Mississippi, and 
the more elevated character of the adjacent country renders 
the air far less humid and the prevailing winds in general 
more agreeable than in the immediate valley of that river. 
Ordinarily the peach is in full flower quite early in March, 
and the forest in full leaf by the first of April. But as a just 
estimate of climate can be drawn only from daily and accu- 
rate meteorological observations, I will here insert the follow- 
ing table, being an abstract of much more detailed observa- 
tions for the year 1840, following the same with such other 
remarks as the farther elucidation of the subject may seem to 
demand. 



Goulding on the Medical Topography of Arkansas. 325 



'Annual, | 


iJanuary, 

February, 

March, 

April, 

May, 

June, 

July, 

August, 

September, 

.October, 

November, 

1 December, 


[Months. 




00 00 O CO CO OD 00 00 — J 
tOWOT00 05lOCO-irfi.i-^OOM 


Highest 
Degree. 


'I'he 




tOlOCOCnOlOlOiCntf^COtO!-^ 
CO to 00 ff^ Go CO o to 


Lowest 
Degree. 


aiour.T; 


ai 
to 


UxOCnH-CDCDOOOhf^-iOO 


Mean 
Temperature. 


leter. j 




1-k to CO to 1-^ to 
tO-^CD^CO^tOOt*^GO«Oai 


Hottest day. 




CO to to '-^ >— to 
i-'«iaico>f^h*^-itoi-'Ot-^t-i 


Coldest day. 


Co' 


C04^CntOtOC0tOtOt-^»-^C0CS 


Days 1 N. 




OS 
to 


CnC0ff^i£».C0tOI-^>J^t-'>t^C0Cr< 


Days 1 N.W. 




Oi 


i-'l00<O'^CT5C0C0*>-t0C0Cr< 


JJ d) S [ IN . . 






ciocococootocooitocjco 


Days • 




CO 

CO 


rf^tOCOOiCOtO'-'OJtO>-'CO*>. 


Days"| S. Y^. 


c- 


Cn 

to 


tOO<4^-^i-'i-^-3rf^OOCO-3tO 


Days 1 S. 






^O^P'<y^P>.C-l^^^O^^^a500OltO 


Days 1 S.W. 






tO-J^tOi-'COOOCOOOCOOtO^l 


Days 1 W. 




in 


West, 

South, 

West, 

South, 

West, 

West, 

East, 

N. East, 

N. East, 

N. N. E. 

East, 

iSouth, 


Prevailing. 




to 

00 


h-^tOtOtOtOtOtOtOt-'h^'-''-' 
0>Ot---0><^lO>f»Cli4^ 00 00CO 


Days 1 fair. 


<' 


081 


mooO'-atocicicicoH-kOo 


Days 1 cl'dy. 


V^eath 


-J 


4:>.tti.OOC5^]tOO-<rfi.tOOOi-^J 


Days 1 rain~ ' 


CP 




tOtOOOOOOOOOOi-^ 


Days 1 snow. 






Q^'*a- 


Prevailing 





It is proper here to observe that, in regard to the position 
of the instrument, times of noting, &c., in the tables of which 
the above is an abstract, the indications given on this subject 
in the "Regulations of the Medical Department of the Tnitcd 
1 * 



326 Goulding on the Medical Topography of Arkansas. 



States Army" have been strictly observed. Range for the 
year, seventy-seven. Coldest month, January. Hottest month, 
August. As it respects temperature, the past may be consid- 
ered an average year in this locality, but in regard to wea- 
ther it must be stated that the amount of rain and the propor- 
tion of cloudy to fair has been greater than usual. The pre- 
vailing winds also in this locality during the hot season are 
usually south and south-west; in this respect however the 
table will show a decided prevalence of east and north-east 
winds during the months July, August and September, 1840. 
This fact (which, indeed, was the subject of frequent remark 
at the time) is believed to have had an important agency in 
producing the very unusual severity and prevalence of fever, 
which afflicted this place and vicinity the past season, as will 
appear more fully in the sequel. 

Diseases. — The past season as before intimated has been 
characterised by an unusal prevalence and severity of inter- 
mittent and bilious remittent fever. Very early in August 
these forms of fever assumed a grave character and became 
unusually prevalent^ at the same time an early tendency to 
general prostration or, in other words, a typhoid diathesis 
seemed to mark the progress of the disease: emetics early, 
followed by mild cathartics and mucilaginous drinks, with 
cold affusions, blisters, and especially later in the attack, the 
extensive application of mustard, gained an increasing confi- 
dence as the disease progressed. It is worthy of lemark here 
that sorc-mouths, unusually protracted and obstinate in their 
character, often followed; nor did these follow only in cases 
in which mercurials entered the plan of treatment; in very 
many of these cases the gums would remain in their normal 
condition while the buccal portions of the mouth and the 
tongue were the [seat of corroding ulcers, tumefaction and 
intense pain. In these cases Labarraques' liquid was found a 
most efficient, indeed an invaluable local application. In 
general the lancet, as also protracted purging, was ill borne, 
and it soon became manifest that an object of primary impor- 
tance was to husband the general strength for a sequel of pro- 



Gould ing on the Medical Topography of Arkansas. 327 



traded debility, as insidious and dangerous in its character 
as it was sure to follow. Indeed, when contrasted with the 
degree of violence attending the invasion and progress of the 
attack, the period nvalescence was in every case peculi- 
arly protracted and critical. This aggravated prevalence of 
fever subsided early in October, since which time up to the 
date of this paper, the health of the locality has been com- 
paratively good. It is not to be inferred that the disease at 
any time assumed that malignant type; or ran its course with 
that rapidity which has sometimes characterised the preva- 
lence of epidemic fevers in still more southern and more un- 
favorably located towns. The interments in the city during 
the four months ending on the thirty-first day of October, 
were one hundred and five, of which number eleven were 
colored persons, and thirty-five were children under ten years 
of age. Population as before stated two thousand and four 
hundred. This proportion of mortality to the number of in- 
habitants is believed to be at least three-fold that of preced- 
ing years at the same period. When the commercial location 
of this town and its rapid growth during the last two years 
are considered, it will readily be inferred that a large propor- 
tion of the deaths were of non-resident or unacclimated per- 
sons; this was strikingly the case; indeed comparatively few 
of those long resident in the locality have fallen victims to 
the diseases of tlie season, with which they have suflered in 
common with others. 

In searching for the causes of the peculiar cast and strength 
of the epidemic influence of this locality the past season, we 
are as in most cases of the kind not fully satisfied; much we 
think may be set down to the fact before stated in regard to 
the winds coming upon us during the hot season from an 
unusual and unfavorable quarter — and also to the fact that the 
great annual or June rise in the Arkansas river occurred 
some four weeks later in the season than is common, and the 
overflow in central Arkansas was unusually great. The pre- 
ceding season, to wil, that of 1S39, was one of good health 
though characterised by uniform *nd highly sustained heat 



32S Goulding on the Medical Topography of Arkansas. 



and protracted drought, so much so that many wells of the 
town were dry and others unfitted for use; the winter follow- 
ing (that of '39 and '40), was marked no peculiarities. If 
we except the season in question, th^ past history of this 
place will put it in an enviable rank for health among the 
towns of the south-west. Yellow-fever has never appeared 
here, nor has cholera, only as it was imported; generally 
speaking there are no prevailing diseases save intermittents, 
which are usually of a mild grade and readily yield to appro- 
priate treatment. Pulmonary consumption can hardly be 
said to have an existence, at the same time complicated pleu- 
risies (pneumonia biliosa) are not uncommon during our win- 
ters, and are the most to be dreaded of any attacks incident 
to that season; scarlatina occasionally makes its appearance, 
and instances of chronic rheumatism are not infrequent. 
Once in the past history of central Arkansas a disease called 
the "cold-plague" had a brief and limited, but for the time a 
very fatal existence in Conway county, fifty miles above Lit- 
tle Rock, rapidly currying ofl" a number of the inhabitants. 
Two cases (answering to the above disease as it has been de- 
scribed to me), terminating fatally within thirty-six hours, in 
somewhat aged subjects and of impaired constitutions, have 
fallen under my observation tlie jiast season; these attacks 
consisted of a violent congestive chill, if I may be allowed the 
expression, from the almost paralysing effect of which the sys- 
tem was unable to rally. 

Next, in regard to jirevalence and delelereous agency on 
health and life in this place, may be mentioned, diarrhoea, dysen- 
leria, croup, cholera infantum, and dropsies. In conclusion 
it may be remarked )hat this climate is not subject to as great 
a variety of diseases as portions of our country farther north. 
Fever in its multifarious forms far outweighs all others; and 
it is believed that when the local causes incident to all new 
districts, tending to aggravate this class of diseases, shall have 
more fully passed away, this place will be noted for its salu- 
brity as it now is for its beautiful and commanding location. 

January 1841. 



Ballard on Pericarditis. 



329 



Art. II. — Extraordinary case of Pericarditis. By Chester 
G. Ballard, M. D.,'of Greencastle, Indiana. 

I have denominated the following case extraordinary from 
the fact that I have neither met with the like, nor in my inter- 
course with the profession have I had one of the kind report- 
ed to me — and after the most diligent search through many 
volumes of Medical Journals, and all the standard works in 
my possession, I am unable to find an analagous case. 

About three weeks since I was called in the night to visit 
an orphan male child between five and six years old, at the 
residence of its grand-mother in this place, in consultation 
with the attending physican, who informed me that the child 
had been under his treatment for several days with the follow- 
ing symptoms: slight fever, coated tongue, tumid abdomen, 
slight cough, restlessness, and constant picking of the nose. 
Treatment — vermifuge medicines, calomel and Dover's pow- 
der. Under this medication the febrile symptoms had been 
to some extent relieved, but no worms dislodged. 

The cause of alarm at this hour, was sudden dyspnoea and 
restlessness, which however had much abated before my arri- 
val. I found the mucous membrane of the nose, mouth, and 
fauces in a high state of irritation — pulse feeble and quick, 
but not intermitting — abdomen very tense, without the least 
apparent tenderness — fluctuation distinct. I learned from the 
family that the child had been fretful, peevish, and sickly, 
since it was seven or eight months old, about which time it 
lost its mother. I also understood that it had been subject to 
severe spells of crying, at the same time manifesting the 
strongest indications of pain, which, when its judgment was 
sufficiently matured, it always located by putting its hand 
upon the sternum. Walking up hill, or the playful exercises 
of childhood always produced difficulty of breathing — appe- 
tite had been uniformly good, and bowels regular; but not- 
withstanding its uniform appetite and the healthy function of 



330 



Ballard on Pericardilis. 



all the chylopoietic viscera, marasmus had set its signet upon 
him, and marked him for a victim. 

I gave it as my decided conviction there was serous effu- 
sion in both the great cavities, and that vv-orms had nothing 
to do in the matter — and that death was inevitable, I advis- 
ed the gentleman in attendance to apply an epispastic from 
the upper part of the sternum to the umbilicus — to give small 
portions of jalap and cream of tartar at proper intervals until 
catharsis was established, and support the strength of his pa- 
tient with appropriate means if occasion should require. 

Following day — blister looked fine — several dark, bilious 
dejections from the bowels — breathing short but easy as com- 
mon — mucous irritation almost disappeared — copious secre- 
tion from the kidneys, which were torpid the night before — 
abdominal tension much less. After which I saw him no 
more until I was requested by the physician to make a post- 
mortem examination, which was done sixteen hours after 
death. 

Autopsy. — When separating the cartilages of the ribs in 
removing the sternum, there was a discharge of about half a 
pint of pale yellow serum containing no flocculi — this I was 
prepared to see — sternum being removed, the pericardium 
presented itself to view, filling almost the entire cavity of the 
thorax, which I supposed to contain a similar fluid, but on 
making an incision I was surprised to find it filled with heal- 
thy looking pus, and to the enormous ajnount at least of two 
quarts. The lamina of the sac were greatly thickened, the 
outer one seemed completely united with the mediastinum — 
its attachment to the cordiform tendon of the diaphragm 
much extended — the lining membrane rather more pallid than 
natural — no lesion in its structure. The heart was natural in 
color, its ventricles and valves all sound, but it was soft; the 
softening however appeared to be nothing more than a ten- 
dency to general decay — all the muscles were flaccid. Lungs 
collapsed and contracted until neither lobe would measure 
more than two and a half inches from base to apex, and in 
external appearance resembling glandular bodies, and posses- 



Ballard on Pericarditis. 



331 



sing, when submitted to the test of the senses, about the same 
density as that of the spleen — they exhibited no marks of past 
or present inflammation, and could not, I should presume, by 
the greatest expansion of which they were capable, have con- 
tained more than three or at most four cubic inches of atmos- 
pheric air — the pleura on both sides possessed all the firmness 
and brilliancy of that of the most healthy subject. The cause 
of the serum in the chest was probably deficiency of absorp- 
tion — as also that of the abdomen, which also contained up- 
wards of a pint of colourless serum. The abdominal viscera 
were all sound. 

The great singularity of this case seems to consist in three 
particulars, viz: the length of time the disease had existed; the 
serous membrane of the pericardium putting on suppurative 
action so perfectly; and the enormous quantity of pus secre- 
ted. That it was insidious in its character should not be 
thought an anomaly, for that is one of its striking character- 
istics. Laennec acknowledges that it is as frequently mistaken 
as recognised, even by himself. With regard to the slow pro- 
gress of the disease in the above case, we think there is no 
reasonable doubt, when we consider the sickly character of 
the child from the time it was seven or eight months old up 
to the day of its death; constantly complaining of pain in the 
thorax, and shortness of breath following the least active ex- 
ertion. An argument miglit be drawn with great force to 
sustain this position from the condition of the lungs. But the 
serous membrane producing such perfect purulent secre- 
tion and to such extent, is what we think the most singular 
feature in the case. Dewees remarks that the pericardium 
acts from laws of its own; this case seems to favor that opin- 
ion. The cough mentioned at our first visit, was by no means 
a concomitant of the chronic disease. The only acute disease 
with which it was ever afflicted, that of mucous irritation, 
was always accompanied with a slight cough. 

December, 1842. 



332 



Sawyer's Cases and Observations. 



Art, III. — Miscellaneous cases and observations. Read before 
the Vincennes Medical Society, November, 1842. By Dr. 
J. S. Sawyer, of Vincennes, Indiana. 

On the 9th May, 1841, Mrs. E. was delivered of a delicate 
female child exhibiting the natural appearances, except a large 
ventral hernia. This tumour, about two and a half inches in di- 
ameter, at its base, occupied the lower and anterior portion of 
the symphisis pubis. The surface presented a fiery red appear 
ance, and was covered with small elevations, resembling fungous 
excrescences, at the side of each of which was a small punc- 
ture. The whole tumour discharged an irritating, ichorous 
fluid. Its size varied with the different degrees of distention 
of the bowels. Fearing either ulceration or gangrene, I di- 
rected the most soothing applications, and the most scrupu- 
lous care to prevent chafing. 

This being, to me at least, a novel case, I requested my 
friend Dr. Posey to see it, who agreed with me that nothing 
could be done at that time for permanent relief. As I had 
apprehended, the surface soon began to ulcerate, and in a 
short time so large an opening was formed, that a great por- 
tion of the bladder was protruded through it. It now appeared 
evident that the abdominal parietes were entirely wanting, 
and that the hernial sac itself was exposed. As to the pre- 
cise nature of the connexion of the tumour at its circumfer- 
ence, with the integuments of the abdomen, I cannot hazard 
an opinion. The child during the month contracted the in- 
fection of pertusis, which, together with the irritation of the 
hernia, soon carried it off. A post-mortem examination would 
have been desirable, and might have shown the upper portion 
of the pubes to have been wanting. But owing to the deli- 
cate health of the mother it was not proposed. 

The complaints arising from inflammation and irritation of 
the spinal cord, have of late attracted much attention and 
been the subject of many dissertations. Like most new things 



Sawyer's Cases and Observations. 



333 



this discovery has no doubt been overrated, and spinal irrita- 
talion has been made to account for the production of ail- 
ments not easily explained otherwise — ^just as we denominate 
many complaints and symptoms nervous, which we do not 
understand. Believing however, that spinal irritation does 
not receive undue attention in this region, I shall relate a 
case or two which may serve to show some of the anomalous 
symptoms that may be produced by it. In the fall of 1S40, 
I was called upon by a lady of my acquaintance aged about 
thirty-five and requested to prescribe for her. She stated that 
for several days she had been unable to speak above her breath, 
felt general debility, and particularly, a weakness of the upper 
extremities. She had had several attacks of this kind before, 
(which, like the present, had appeared without any apparent 
cause), for which digitalis had been prescribed and taken without 
much benefit. The patient's constitution had been much shat- 
tered, and she had had some years before, an attack of htem- 
optysis. I prescribed an expectorant mixture of syrup of squills, 
antimonial wine, and elixir paregoric, which affording no re- 
lief, the patient in a short time called again. It now occur- 
red to me that the aphonia might depend upon spinal irrita- 
tion and a consequent partial paralysis of the nerves supply- 
ing the organs of voice. Finding, upon examination, great 
tenderness of the lower cervical and one or two of the upper 
dorsal vertebra?, I prescribed a blister, which had scarcely 
drawn before complete relief was obtained. Nearly two years 
have since elapsed, but there has been no return of the com- 
plaint. Sometime afterwards, I attended a lady who was 
subject to attacks of aphonia and weakness of the upper ex- 
tremities, upon making any unusual muscular exertion. The 
same condition of the spine was found to exist, and the same 
treatment was successful as in the other case. It may be well 
to state that this lady has since had an attack of haemopty- 
sis. 

It is well-known, that the phenomena of voice depend upon 
the internal laryngeal, and the recurrent nerves, which are 
o 



334 



Sawyer's Cases and Observations. 



branches of the par vagum, and are distributed, the former to 
the epiglottis and muscles moving the cartilages, and the lat- 
ter to the larynx and trachea. The spinal accessory, which 
with the glosso-pharyngeal, and par vagum makes up the 
eighth pair, takes its origin from twigs of the fourth, fifth, 
sixth, and seventh cervical nerves, and after uniting with the 
other two divisions of the eighth, is finally distributed to the 
muscles of the shoulder. This connexion seems to explain 
the production of aphonia, pain in the shoulder, and weakness 
of the upper extremities, from an irritation of the spine ai 
the origin of the spinal accessory nerve. 

Inflammation and congestion of the brain, prevailed to an 
alarming extent in some parts of the country, during the last 
winter. A striking feature of this epidemic, was the rapidity 
of its progress. I shall attempt to give some account of these 
complaints as they occurred within the circle of my practice, 
not so much with a view of saying anything new, as with 
the hope of stimulating other members to communicate the 
result of their observations and reflections. In the early part 
of February last, I was called to visit a boy aged about six 
years, the son of a gentleman who had already lost another 
child, after a few hours illness. He complained of great sore- 
ness of the limbs and the whole surface of the body. Lying 
in bed produced great uneasiness and pain, and when I at- 
tempted to examine his pulse he would cry out with anguish. 
The surface was most of the time cool, though in some part 
of the day, there was slight reaction. The skin was covered 
with small, smooth, dark-red points, not much larger than a 
pin's head. This was a case which would no doubt have been 
called at one time, cold-plague; and Saalmon in his account 
of epidemic inflammation of the brain, says, that it sometimes 
made its appearance with imperfect reaction, and great 
pain and soreness of the limbs. Considering a strong ten- 
dency to congestion of the brain manifested in this case, I 
prescribed the semicupium, blisters to the extremities, and a 
large dose of calomel. I did not see the patient again, but 
understood that the calomel did not operate for twenty-four 



Sawyer's Cases and Observations. 



335 



hours, when a large quantity of black bilious matter was dis- 
charged, with considerable amendment of the symptoms. This 
case might have recovered under a vigorous course of counter- 
irritation, and evacuation from the liver, but having no further 
treatment, it went on to a fatal termination. Before I left the 
house, the infant in the cradle was observed to be more fret- 
ful than usual. A simple prescription was made, hoping that 
it was not seriously indisposed, but in about thirty-six hours 
it expired. 

In a few days I was requested to visit a boy about four 
years old, in the same neighborhood. I arrived about two 
o'clock, P. M. I was informed that he had not appeared in- 
disposed until the morning of the same day, when he com- 
plained of his head, and growing rapidly worse, the family 
sent for aid. When I arrived the patient was nearly insen- 
sible. The surface was rather cool, and covered with small 
smooth points of a purple color — pulse small and weak. 
The eyes had a vacant appearance, and no impression was 
made upon the pupil by the approach of a candle. Con- 
sidering the rapid progress of the case, and the deeply con- 
gested state of the brain, I could not give the parents any 
encouragement. The patient however was immersed in a 
warm bath, which produced great prostration. Blisters and 
sinapisms were then applied to the extremities and stomach, 
a large dose of calomel was, with much difficulty, administer- 
ed, and another directed to be given in two hours if practi- 
cable. The progress of the disease was not at all arrested, 
and, in twenty-six hours from the time when he first com- 
plained, the patient was a corpse. Just before I left, the 
youngest child, probably ten months old, was observed to be 
fretful; but I was not asked to prescribe, and did not examine 
it. In six hours it died. I do not know what were the symp- 
toms, but suppose they were the same as in the other case. 
The case here related I consider one of congestion of the 
brain; a disease which, so far as I know, is of much more 
rapid progress than inflammation, properly so called, of that 
organ. 

I shall briefly relate a case of inflammation of the braic 



336 Sawyer's Cases and Observations. 



which came under my care in the latter part of March. 
The patient was a little girl about five years old. She had 
been complaining some days before I was called, but was not 
considered dangerous until Thursday, when she became so 
much deranged as to alarm the family and induce them to 
send for aid. I arrived about two o'clock, P. M. The little 
patient could now seldom be made to answer a question, and 
when she did, the answer was altogether incoherent. The 
face was flushed, the eyes red and suffused, the pupil dilated. 
She would frequently rise in bed as if much afl^righted, mut- 
tering inarticulately. The hands were tremulous, and the 
whole features indicated great nervous excitement. Vomit- 
ing, one of the usual symptoms in this complaint, was pre- 
sent in this case. About a dozen large worms had been thrown 
from the stomach. The pulse was weak and frequent. In 
view of the rapid progress of the case, the difficulty of ad- 
ministering medicine, and of the fact that the second stage of 
the disease was already present, I considered this case as hope- 
less. I however administered a large portion of calomel and 
rhubarb, and left several others to be given two hours apart 
if possible; and a strong preparation of pink and senna was 
directed to be given in as large doses and as often as practi- 
cable. Blisters were applied to the temples and extremities. 
In the evening the medicine had not operated — directed it to 
be continued through the night when practicable. The vomiting 
continued at intervals all night, and the medicine, notwith- 
standing the use of injections, did not operate until eleven 
o'clock next day, when large dark evacuations were had, to- 
gether with twenty-six large worms in one knot. By this 
time, however, the patient was rapidly sinking, and expired 
about one o'clock, less than twenty-four hours from the time 
when I first saw her. 

I propose to close these imperfect remarks with a few re- 
flections. Inflammation and congestion of the brain, though 
they may arise from the same cause, yet obviously do 
not consist in the same condition of the brain. In other 
words, like causes do not produce like effects, in all system? 



Sawyer's Cases and Observations. 337 

and at different times. The most common cause of both in 
this climate, is doubtless cold. This cause may, in one indi- 
vidual, produce inflammation in the substance of the brain or 
its membranes, ending, unless arrested by timely depletion, in 
gangrene or effusion; while in another, so great a shock is 
given to the nervous system that no re-action takes place, and 
the powers of life seem at once to succumb. Whether in 
congestion of the brain, the condition of that organ is essen- 
tially inflammatory, I shall not presume to decide. I believe 
not. In general we understand a congestion of any part to 
consist in an over-distention of the vessels of that part, and 
a sluggish motion of the contained fluid, without inflamma- 
tion. There is no doubt that the direct effect of cold is to 
weaken the action of the heart. This principle, so easy of 
demonstration if necessity required and time permitted it, 
will be taken for granted, in attempting an explanation of the 
proximate cause of congestion of the brain. The heart being 
weakened in its action, the blood must necessarily accumu- 
late in the right side of the heart and in the large veins lead- 
ing to it, for the reason that the organ has not power to free 
itself from the burden, by filling the arteries. The blood be- 
ing, consequently, imperfectly arterialized, does not exercise 
its natural amount of stimulus upon the heart, which tends 
indirectly still further to weaken its action. This state of 
congestion occurs to a great or less extent in the cold stage 
of every paroxysm of fever, but in these cases, reaction com- 
ing on, restores the balance of the circulation. The causes 
which tend to render the amount of congestion relatively 
greater in one organ than another, may be various; as consti- 
tutional or accidental weakness of the part, predisposition, 
&c. In the operation of any cause weakening, in a great de- 
gree, the action of the heart and producing consequent' venous 
congestion, the brain, returning as it does so large a quantity 
of blood to the right aurich, must to a very great extent be 
implicated in that congestion. But when cold produces such 
inroads upon the nervous system, as to prostrate at once the 
vital energies, so that reaction cannot take place, it is but 
2 * 



338 Sawyer's Cases and Observations. 



natural that the brain, which is the centre of that system, 
\ should be the principal seat of congestion. This tendency, 
so natural in itself, may be increased by any source of irrita- 
tion in other parts, the effects of which are most naturally 
transmitted by sympathy of parts to the brain. I am per- 
suaded that in the epidemic of last winter, this source of irri- 
tation was the presence of worms. I am convinced from 
observation and reflection, that this cause, by producing an 
undue excitement in the brain, hastened the progress of the 
disease and rendered the fatal result more certain. Indeed, 
there is reason to suspect that in some cases of the kind, 
worms are the main cause, and the application of cold, merely 
a concomitant. So well am I persuaded of the mischief they 
produce in many affections of the brain, that I consider their 
expulsion as one of the first indications, in the early stage of 
the complaint. 

It may be useful to attempt a diagnosis between inflam- 
mation and congestion of the brain. Inflammation is known 
by the general heat of the skin, the flushed countenance, the 
red eye, pain, generally acute in some part of the head, vom- 
iting, early delirium, and contracted pupil. The pulse is said 
to be sometimes full, but generally hard and small. In con- 
gestion, the reaction is feeble, and in the worst cases there is 
none; consequently, there is little or no external heat. The 
face, instead of being flushed, is pah, or has a darker hue than 
natural. Instead of the delirium and nervous agitation, there 
is languor, comn, soon followed by insensibility. The pulse 
is weak, soft, and compressible. The period of insensibility 
occurs much sooner than in inflammation. There is reason 
to believe that the immediate cause of death in congestion, is 
not, as in inflammation, the process of efliision or gangrene, 
but the compression of the brain from over distention of its 
vessels or from their actual rupture. 

With regard to the treatment of these complaints few- 
words will suffice. Where they occur in a violent form, as in 
the epidemic of last winter, nothing less than the most vigo- 
rous course of treatment in the very onset of the disease. 



\ 



Sawyer's Cases and Observations. 339 

can be of any avail. The misfortune is that, not apprehend- 
ing danger, the friends do not call a physician until the dis- 
ease has made much progress; when, even if he could always 
have the necessary means at hand, the stage for active deple- 
tion is past. Where however the patient can be seen in time, 
there can be no doubt of the absolute necessity of the abstrac- 
tion of blood, though in the cases of children it must be done 
cautiously, as it is admitted that they do not bear blood-let- 
ting with equal impunity as adults. In inflammation, bleed- 
ing from the arm and cupping seem to answer the indication; 
but in congestion I think bleeding from the arm contra-indi- 
cated. Cupping the temples and nape of the neck, and open- 
ing the jugular vein appear to afford the only rational means 
of relief, so far as blood-letting is concerned. The next step 
is to remove all causes of irritation, and of these in cases of 
children the most important is worms. Ten grains of calo- 
mel should be given to a child five years old, in bad cases, 
repeated every three hours until it operates. A strong prep- 
aration of pink and senna should follow the first portion oi 
calomel, and be repeated every hour in as large doses as the 
patient will swallow, until free evacuations have been procured 
from the whole. There should be no waiting or hesitating 
in this course, for when worms are present proving a source 
of irritation, unless sufficient medicine be administered before 
stupor occurs, to operate freely in a short time, the case will 
inevitably go on to a fatal termination. The calomel is always 
indicated, because, v/hen it acts upon the liver producing 
black discharges, it derives powerfully from the head, and 
when worms are present it is doubly required. Even when 
no worms are expelled, the calomel, pink and senna are 
beneficial, because they seem to quiet them, and, operating 
briskly, these medicines produce the timely removal of other 
offending matter from the stomach and bowels. We dare not 
wait for the slow operation of these medicines given in the 
usual way, though they act more surely. A few hours brings 
stupor, when it is very difficult to give medicine in sufficient 
doses. Besides, the free operation of medicine after that time 



340 Falconer's Ccesm-ean Operation. 



seems to hasten the fatal result. Blisters should be applied at 
an earlier period than is usual in affections of the head. In 
all doubtful cases, if blisters are used, it should be done imme- 
diately upon the appearance of a disposition to coma. If 
delayed, they will frequently not act at all. In inflammation 
of the brain which runs its usual course, it is better to defer 
their application until the violence of the disease is somewhat 
abated. 



Art. IV. — Casarean Operation on a Dwarf. By Cyrus Fal- 
coner, M. D., of Hamilton, Butler county, Ohio. 

Perfect success is not always the test of merit or skill; but 
it is sometimes the chief motive in reporting cases for the 
public eye. I am not positively sure that some influence of 
this kind has not prevented me from offering at an earlier 
date a report of the following case, which has certainly some 
peculiar and striking features, however barren of brilliancy in 
the result. 

On the 6th of July, 1840, I was called to visit Miss 

, of Ross township, in the south-western part of this 

county (Butler), in labor with first child. The physician in 
attendance was Dr. Praether, an intelligent practitioner of 
Venice, near which village the patient resided. She had been 
in labor since the previous midnight; I arrived about 22 
P. M. 

I was not a little surprised to find the patient a dwarf, just 
three feet six inches in height, with a form very illy proportioned. 
Her head was perhaps of normal size, and her trunk not greatly 
inferior in breadth to the ordinary standard, but longitudinally 
reaching little over its proportion of her diminutive stature. 
The left foot of the foetus was presenting at the os externum, 
and Dr. P. informed me he had felt the toes of its fellow; but 
had been unable to introduce his hand so as to grasp the foot 



Falconer's CcBsarean Operation. 



341 



and bring it down. I proceeded to examine her; and carry- 
ing the finger to the superior strait, 1 immediately discovered 
a mal-conformation of the pelvis. The sacrum projected to- 
wards the pubis so as to give the superior strait the character 
of a fissure; the antero-posterior diameter being certainly 
not over one inch and three-fourths. The leg of the present- 
ing foot occupied the full breadth of the fissure, affording an 
evidence but too conclusive that nature was not competent to 
the delivery. The os uteri was well dilated, and the pains 
incessant and severe. Carrying ray hand over the abdomen 
I found the uterus occupying a diagonal position; the fundus 
extending high into the right hypochondriac region. 

Her mother assured us that the mal-formation was congeni- 
tal, and that she had observed the pelvic obliquity soon after 
birth: but from a history of the early childhood of the pa- 
tient we v?ere satisfied it was the result of rachilis. 

What was to be done? The strength of our patient was 
flagging in an unavailing travail. Her delivery j)eri;ias natu- 
rales, was evidently impossible. Shall we sacrifice the foetus 
in an attempt to save the mother? Can we, after awaiting its 
death, remove it piecemeal? These questions were rapidly 
and anxiously revolved in our minds. Had the head present- 
ed, its reduction and the use of the crotchet would of course 
have presented themselves, though had that been the case 
there was not room, I apprehend, for the passage of the base 
of the cranium. Under the circumstances, we were soon 
brought to the conclusion that the only hope for either child 
or mother was in the Casarean section. This might save 
both, without it the loss of both was inevitable; for we had 
not sufficient confidence in the division of the pubis to induce 
us to canvass its merits. 

Quietly withdrawing the mother of the patient, and one of 
her friends, we stated to them frankly the situation of the case, 
and the alternatives. They were less surprised than I had 
anticipated, the dwarfish stature and disproportions of the 
girl having prepared them for something of the kind. We 
next communicated our views to the patient herself— she ex- 



342 



Falconer's Ccesarean Operation. 



hibited but slight emotion, and promptly agreed to the opera- 
tion. 

We then proposed sending to Hamilton — eight miles — for 
additional comisel: but to this the patient strongly objected, 
insisting she could not endure the delay, and imploring us to 
proceed at once to the operation. Her mother joined in the 
request, and indeed we were satisfied that every hours delay 
lessened the prospect of a favorable result. The most propi- 
tious time, according to all writers on this subject, I believe, 
had already long since passed. 

The operation resolved upon, we set about preparing for it. 
Ligatures, adhesive strips, lint, compresses, and a broad ban- 
dage were arranged ready for use. The instrument selected 
was the common scalpel. 

Placing the patient upon her back on the bed which she 
was finally to occupy, with the lower extremities partially 
flexed, and having the walls of the abdomen compressed by 
assistants, so as to fix the uterus and prevent the escape of the 
omentum or intestines, I proceeded to make the first incision. 
In order to make myself understood I will repeat that the 
fundus of the uterus extended high into the right hypochon- 
drium, overlapping, and to a considerable extent, dislodging 
the liver from its position. It was necessary to make the in- 
cision somewhat oblique, beginning at the upper part, near 
the right margin of the linea alba, and crossing towards its 
centre in the descent towards the pubis. The usual direction 
is to commence below the umbilicus: but in this case the 
shortness of the abdomen made it imperative to begin con- 
siderably higher up, in order to get an opening large enough 
to extract the foetus. This case seemed to me a wonderful 
illustration of the capacity of nature to adapt herself to cir- 
cumstances, however straitened. The liver and stomach ap- 
peared to be crowded entirely out of their proper location, 
pressing of course, in turn, upon the diaphragm and 
other viscera, and yet the functions of animal life had 
been but little disturbed. With the first sweep of the knife, 
I divided the abdominal integuments to within an inch or an 



Falconer's CcBsarean Operation. 343 



inch and a half of the pubis, exposing the aponeurotic ex- 
pansion which forms the linea alba, the whole distance: this 
was then carefully divided, and the peritoneum presented 
itself. Making a small orifice in this latter membrane at the 
upper extremity of the incision, I inserted a couple of fingers 
and slightly elevating them divided it; the fingers acting as a 
director, and protecting the parts beneath. At this part of 
the operation, much diiBculty was experienced in preventing 
the escape of the intestines. The uterus was opened, observ- 
ing tlie same caution as with the peritoneum, and the foetus 
was exposed, its back presenting to the incision. Although 
I began my incision considerably above the umbilicus, such 
was the relative size of the child that I found it impracticable 
to extract it, until I had extended the opening in each di- 
rection; approaching nearly to the cartilage of the lower 
true rib above, and the pubis below. During my eflbrts to 
accomplish the delivery, considerable extravasation took place. 
The relative size of child and mother can only be conceived 
by the reader, when he remembers the height of the mother — 
3? feet — and learns that the child was about the ordinary 
size, weighing, by conjecture, from seven to eight pounds. 

I at length succeeded, by grasping the thighs in elevating 
the breech, and delivered the child, as in a breech presen- 
tation; it soon cried lustily, and was separated from the cord. 
The uterus now contracted powerfully, the placenta was ex- 
pelled, the extravasated blood removed as much as possible, 
and we then proceeded to dress the wound. 

Four or five points of the interrupted suture were employed 
— long adhesive strips were applied between the sutures, 
leaving a space at the lower portion, for the escape of any 
discharge that might accumulate. A broad compress was 
next applied, and the whole covered with a broad firm ban- 
dage tolerably tight. 

During the operation, the patient made very little com- 
plaint; she now said she felt very comfortable, and expressed 
much gratification at being relieved by an amount of suffer- 



344 Falconer's Ccesarean Operation. 



ing, so much less than she had apprehended. An anodyne 
was administered, and finding her at the end of a couple of 
hours still comfortable and inclined to rest, I left her, and 
rode home, solacing myself with the pleasing hope of a favor- 
able result. Ere morning, however, inflammation began to 
be developed. On visiting her next day, I found the tongue 
white, the pulse quick and frequent, the abdomen swelled, 
tympanitic, and tender, great thirst, with all the evidences of 
a high degree of inflammation. Dr. Praether residing near 
her, saw her frequently; but it is not necessary to detail the 
treatment, which did not differ from that usually pursued in 
inflammation of the abdominal viscera. She died on the 
eighth. 

The child did well, and is now a vigorous healthy and well 
formed little girl. 

An additional link in the chain of sympathy excited in my 
bosom for the luckless subject of this notice, was the fact that 
she was the victim of a human fiend, in the shape of her own 
uncle! 

A word as to the proper time of operating and I have done. 
Caesarian section must necessarily be an exceedingly rare 
operation in any country, and more especially in the sparse 
population and well-formed pelves of our country. This in- 
frequency, with the want of observation and experience which 
flows from it, will ever tend to produce hesitancy and indecis- 
ion in the minds of the medical attendant, and will probably 
very often delay the operation until the most elegible time 
has gone by. The fear of censure will doubtless sometimes 
throw its weight into the same scale; for it is unfortunately 
true, that there are many in our profession who will find fault 
with the practice of a rival brother, whenever it is practica- 
ble to do so. In this case it has been said we were too pre- 
cipitate, and should have had additional counsel. But in fact 
the delay already had, was very possibly a cause of the un- 
fortunate result to the mother. The unfavorable termination 
of nearly all the earlier cases of Caesarian operation in Eng- 



Todd oji Cathartics in Retained Placenta. 345 



land, is attributed chiefly to the late period of labor when the 
operation was resorted to.* 

The continental writers, amongst them Graefe and Bau- 
ddocque, unanimously assure us that the proper time for the 
operation is before the waters have been evacuated, and just 
so soon as the os uteri is sufficiently dilated to permit their 
free discharge. In this opinion Dewees concurs; and no doubt 
such is the proper course where election as to time is with- 
in the control of the attendant. Sabaiier says, "There ought 
not to be too much delay, lest the patient's strength be ex- 
hausted, and the violent eflbrts of labor should bring on an 
inflammatory state of the parietes of the uterus." 

March, 1S43. 



Art. V. — On the Use of Cathartics in Retention of the Pla- 
centa. By Dr. Thomas H. Todd, of Lincoln county, Ten- 
nessee. 

Although much has been said and written on the subject 
of retained placenta, yet we have much to learn about it, as 
indeed about many things in every other branch of medicine. 
It is not my design to write an elaborate dissertation upon 
this topic. My aim, in the remarks that I shall make, will 
be, to direct the minds of practitioners to a certain class of 
remedies which have heretofore, so far as my information ex- 
tends, been overlooked, or entirely neglected by the practical 
accoucheur. I must therefore refer the reader to the standard 
works upon obstetrics, and to the numerous essays contained 
in the medical journals, for a full account of the subject, and 
the general management of such cases; while I shall con- 
fine my remarks to the therapeutic agency of cathartic medi- 
cines, as a means of expelling the secundines under certain 
circumstances. Why cathartics have so long been overlooked 



* Vide Hull's letter, Deiunan.et al. 

a 



346 



Todd 071 Cathartics in Retained Placenta. 



and neglected by the profession, is really matter of much sur- 
prise to me; for we cannot peruse the writings of any one 
upon this subject, without being able to glean abundant evi- 
dence, that goes conclusively to establish the efficacy of this 
class of medicines, in rousing up the dormant energies of 
the uterus. And they will do this, independent of any par- 
ticular irritation or excitement which they may produce upon 
the rectum. The older writers on midwifery discovered that 
there was an intimate sympathy existing between the rectum 
and uterus, and that any undue excitement in the former, 
was readily communicated to the latter organ: hence, they 
early learned the efficacy of stimulating injections in cases 
where they desired uterine contraction. To the correctness 
of this fact all subsequent writers have testified. But why 
this discovery should forestall all further researcli and inquiry, 
respecting the sympathy that might exist between the uterus 
and the bowels, instead of leading to it, is a problem that I 
shall leave for others to solve. In the meantime, however, I 
shall endeavor to prove that this sympathy is not confined to 
the rectum, but extends to the whole alimentary canal. 

All writers in treating of the diseases of the pregnant fe- 
male are unanimous in cautioning us in the use of cathartics, 
lest, say they, the use of this class of remedies should excite 
the uterus, and thereby produce abortion. Now it is well 
known that drastic cathartics when carried to excess, are 
prone to excite the rectum, and to produce tenesmus; but that 
all purgative medicines, when not carried too far, will pro- 
duce this effect, no one will hazard his reputation by assert- 
ing. The late Dr. Dewees says: "The pregnant woman does 
not bear purging so well as one who is not so, and if this 
operation be carried very far, there is a risk of producing 
abortion." In speaking further upon this subject he says: 
"We suggest a caution in the choice of purgative medicines; 
all such as act with great force upon the bowels should be 
avoided; as all such as are classed among the drastic purga- 
tives, as scammony, gamboge, colocynth, aloes, &c.; because 
each of these produces, during its operation, great irritation 



Todd on Cathartics in Retained Placenta. 



347 



and very frequently excites tenesmus. It is this peculiar irri- 
tation which renders any cathartic unsafe which may produce 
it; no matter to which class of cathartics it may belong; for 
if castor oil, magnesia, or any other mild cathartic were to 
produce this effect, it would be equally improper, as any of 
the drugs proscribed above." 

The foregoing quotation serves to show that any purgative 
will sometimes produce uterine contraction: but Dewees 
thinks it will only do so, by first producing a. peculiar irrita- 
tion upon the rectum. He has not, however, attempted to 
prove that castor-oil, magnesia, or any other mild cathartic, 
ever does produce this peculiar irritation upon the rectum, 
when used in moderation. There is no one who appreciates 
the opinions of eminent men, and those in high places, more 
than the writer does; but before we admit them as maxims in 
science, we ought at least to examine the premises upon 
which they are founded. That uterine contraction, when 
there is a predisposition in this organ, frequently follows, ox 
accompanies the action of the bowels produced by any mild 
purgative, is manifest to all who have been in the habit of 
observing their effects upon the parturient female. I see noth- 
ing connected with the uterus, and its sympathies, but what 
goes to corroborate this fact. When the uterus is predisposed 
to contract, as it always is during the retention of the after- 
birth, we see this action excited by the slightest causes, as 
gentle traction upon the cord, friction over the abdomen, 
the application of a cold or wet hand, &c. After observing 
the effects produced by such slight causes, why should we be 
so incredulous as not to believe that an action upon the bow- 
els, sufficient to cause them to throw off their contents, could 
not make an impression upon so excitable an organ as the 
uterus is at such times, independent of producing any particu- 
lar irritation, or tenesmus about the rectum. Denman, in 
speaking of the causes of abortion, says: "The sympathetic 
causes of the action of the uterus may arise from the distur- 
bance of any part, with which the uterus is connected, or dis- 
posed to consent, as is the case with all the contents of the 



348 



Todd on Cathartics in Retained Placenta. 



abdomen." Again he says; "Pain in the stomach, or bow- 
els, or any part contiguous to the uterus, or with which it is 
prone to consent, may disturb it; and if extremely violent, or 
of long continuance, may produce the same efTect." And 
again he continues: "Such medicines as exert a violent action 
on the stomach or bowels, will, upon the principle formerly 
mentioned, frequently excite abortion; and very often are 
taken designedly for that purpose." 

In the American Journal of the Medical Sciences (vol. 
26, no. for May, 1840), Dr. Edward Warren, of Boston, has 
written a valuable paper on retention of the placenta. His 
aim is to prove, by correct data, that there is less danger in 
delay, in such cases, than in the violent means generally re- 
sorted to, for the speedy removal of the secundines. Among 
the cases cited in this essay, are the two following, taken from 
a report of Dr. Lee's: "In the seventeenth case, the woman 
was delivered of a child at the sixth and a half month. The 
cord had been broken off by the midwife, and the parts were 
so much contracted that the hand could not be introduced 
without too much force. The following morning a brisk 
cathartic was given, and in the evening the placenta came 
away whole, without any help, and with no bad result. In 
the nineteenth case, the patient had been delivered of a dead 
child, of six and a half months, twenty-four hours before Dr. 
Lee saw her. An attempt to withdraw the placenta failed. 
The next morning a cathartic w^as given, which excited vomit- 
ing and purging, and during its operation the placenta came 
away in a yellow indurated state — no bad symptom followed." 
This case is directly in point. In case seventeenth, a brisk 
cathartic was given in the morning, and the placenta came 
away in the evening; by which time, the cathartic must have 
been operating. I have very little doubt that the cathartic ex- 
cited the uterus in this case, although the Dr. tells us it came 
away whole without any help. 

During my residence in Starkville, Mississippi, the follow- 
ing cases came under my own observation: 

Case 1st. A woman aged twenty-eight, the property of 



Todd on Cathartics in Retained Placenta. 349 

Richard Ellett, was delivered of a living, and first child. The 
labor was tedious, and the patient much exhausted in conse- 
quence. After the child was removed, I examined the pari- 
etes of the abdomen, and found that the uterus liad contracted 
firmly; but the tumour was high up in the right side. As 
there was no hemorrhage, I used friction, and pulled gently 
upon the cord only, for the first few hours. I then passed my 
fingers along the cord to ascertain if the placenta had been 
detached and thrown into the vagina; but it had not, as I was 
unable to touch any part of it. I then administered the ergot, 
with the view of exciting uterine contraction, and thereby re- 
lieving the patient; but in this 1 was disappointed, as the 
ergot produced no effect. After this failure I thought it best 
to introduce the hand and remove the after-birth, but here 
again I was doomed to meet another disappointment; as the 
soft parts had by this time contracted so much, that any at- 
tempt to introduce the hand, however slow and firm it might 
be, entirely failed. 1 now resolved to give a dose of ol. 
ricini, as the bowels had not been moved since the labor be- 
gan, and to wait the result. In due time, however, the oil 
acted, and with the action of the bowels the pains returned, 
and threw the secundines into the vagina, where the mass was 
readily seized, and removed with the hand twelve hours after 
the birth of the child. 

Case 'id. Prissa, servant of Mr. Hines, was delivered of a 
still-born child near the sixth or seventh month (in Septem- 
ber, 1839). On examination twelve hours after delivery, 1 
found that the cord had been broken off in attempts to re- 
move the after-birth. The parts contracted so much that the 
hand could not be introduced; and the ergot had been given 
but produced no eflect. As the bowels had not been moved, 
I advised that a dose of castor-oil should be given, and its 
operation waited for, as there were no unpleasant symptoms 
in the case. By evening the oil had operated two or three 
times, without producing any pain whatever. I now made an 
examination, but found that the placenta had not advanced 
any. As the patient was resting well, we resolved to leave 
3 * 



350 Todd on Cathartics in Retained Placenta. 

the case for the night to nature. At 10 o'clock next morning 
we gave a dose of pills containing equal parts of calomel, 
rheubarb and aloes. At 6 o'clock, P. M., I was sent for in 
great haste; the woman was in much pain and her mistress 
much alarmed. Soon after my arrival the pills acted upon 
the bowels; and with the first evacuation the placenta was 
expelled, forty six hours after the birth of the child. 

These two cases were communicated to the editor of the 
American Journal of the Medical Sciences, and published in 
vol. ii (new series) no. 3, for July, 1841; with the following 
paragraph by the editor: "The well known sympathy between 
the rectum and uterus, explains the action of purgatives in 
exciting the uterus to expel its contents." This paragraph is 
a fit illustration of the influence that preconceived opinions 
and prejudice always exert over the minds of men. Now, if 
there is any thing, in either of the cases related above, that 
could lead us to conclude that there was any preternatural ex- 
citement, or tenesmus, in the rectum, it is hidden from the 
writer. In the first, the bowels had not been moved previ- 
ously by any medicine, and oil was used on the occasion. In 
the second, the bowels had not been operated upon for the 
last twenty-four hours, and the placenta was expelled after the 
first evacuation. 

Case 3d. I was called, in November, 1840, to see a woman 
the property of Richard Barry. She had been delivered twen- 
"y-four hours before I was called. The placenta had not been 
delivered, and the cord had been broken off by the midwife. 
The soft parts were so much contracted, and so tender to the 
touch, that I could not introduce the hand, without using too 
much violence. I gave ergot in full and repeated doses; but 
without producing any effect upon the uterus. As the bowels 
had not been opened, I gave a dose of Cook's pills. By even- 
ing they operated, producing considerable pain in the uterus; 
but to make sure work, I resumed the use of the ergot at this 
time; and in a little while the placenta was expelled. Noun- 
pleasant symptoms followed. 

Case Ath. This case I did not see, on account of my own 



Todd on Cathartics in Retained Placenta. 351 



ill-health at the time. The patient, however, was my imme- 
diate neighbor, and was treated by my brother, J. J. Todd, 
M. D., of Starkville, Mississippi. Mrs. F. a delicate female, 
and the mother of one child, miscarried in July, 1841, be- 
tween the fifth and sixth months. The after-birth could not 
be delivered at the time, although ergot was used for that pur- 
pose. Next day the cord was broken off, in misuccessful at- 
tempts for its removal. A purgative had been given to open 
the bowels, and when it acted, ergot was again used, but with- 
out producing any effect. As the case was not attended with 
any unfavorable symptoms, no rash means w^ere resorted to. 
Early on the third day however, during the action of her bow- 
els from a purgative dose of medicine, the placenta was ex- 
pelled — without any help, as some writers would say. No 
bad symptom occurred afterward. 

It frequently happens, that all remedies lhat can be 
brought to our aid, fail; and the accoucheur has at last to leave 
the case almost entirely to the efforts of nature. Friction and 
pressure upon the abdomen fail, ergot fails, traction upon the 
cord fails, the hand cannot be introduced with safety, injec- 
tions do not relieve, nor will instruments answer our purpose. 
And yet suffering humanity calls incessantly upon us for re- 
lief. Under these circumstances we ought surely to search 
out, and call to our aid, each and every remedy that will tend 
to relieve the patient, without any detriment. Purgatives, to 
say the least for them, certainly exerted a salutary influence 
in the cases above mentioned, and that, after all other safe 
means had been resorted to without success. 

March, 1843. 



Selections from :3Cmcii'cau aiiti jFoi-eigu Journals. 



Presumption of Survivorship.— By Dr. Krugelstein. The 
cases in which the presumption of survivorship maj' arise, 
are the following. 1. When mother and child both die du- 
ring delivery. 2. When many persons perish at the same 
time, as under the ruins of a falling building, or in a sandpit, 
or by an earthquake, or by the fumes of charcoal; or when 
many perish at the same time by shipwreck, or in drowning, 
when hurled together into an abyss; destroyed in a conflagra- 
tion; simultaneously poisoned; dying at the same time from 
wounds; from hunger or from cold. 

A. On the presumption of survivorship, when the mother 
and child die during delivery, two cases may arise. 1. The 
mother dies during delivery, without bringing forth the child. 
Here there may be a legal question, whether the right of in- 
heritance of the child, though living, but not born, could be 
transferred to a third person. 

2. The mother dies during delivery, and after her death, the 
child is born and found dead, no one having noticed its de- 
livery. 

In the first instance, it must be previously ascertained what 
was the cause of the death of the mother, and what the pre- 
sentation of the child. If the latter is natural, and the parts 
exhibit mechanical impediments to delivery, and the mother 
died suddenly of a nervous aifection, then the presumption is 
in favor of the child surviving. Opposed to this, in the opin- 
ion of J'o'rg, is the case cited by him, of a robust and remark- 
ably healthy peasant woman, who for several weeks previous 
to the full time, suffered under eclampsia gravidarum, and 
during one of these convulsions, without its being noticed by 
any one, brought forth a dead child, with the placenta. He 
remarks, however, that eclampsia usually attacks only heal- 
thy, muscular, and especially full-blooded women; and that 



Presumption of Survivorship. 



353 



the probability of the death of the foetus, either before or 
during delivery, is increased according to the lengih of time 
that the mother has been suffering under the disease. 

But if the position of the child be unnatural, and especially 
if the funis has protruded, we may assume (and above all, if 
the pains have been violent) that the mother died after the 
child. 

In the case of a child full grown, and capable of living, 
born after the death of the mother, the proof by examining 
the lungs is conclusive as to its life. But if we find on it no 
signs of maturity, or of intra-uterine life, the presumption is 
in favor of the mother surviving, and particularly if there be 
marks of putrefaction in the foetus. 

B. When many persons are destroyed at the same time, the 
first inquiry is as to the cause of death, whether by suffoca- 
tion, hunger, thirst, or wounds. 

In cases of suffocation, we must notice the age, condition 
of body, sex, and the position of the dead. In reference to 
age, children and young persons survive old ones. Thus, in 
the earthquake at Calabria, a man and his wife, with their 
child, were entombed by a falling house. On being dug out, 
the parents were found dead, and the girl alive. The nearer 
the individual is to the age of childhood, the less is the neces- 
sity for respiration; and hence, persons of manly age, and if 
not asthmatic, but of sound lungs, survive the aged. 

In reference to the condition of the body, the most impor- 
tant point is the state of the lungs. A person with sound 
lungs will easily outlive another, whose lungs are indurated 
or suppurating, since an unfrequent, but perfect inspiration 
suffices to preserve for a time, the functions of the lungs, 
while a short and confined one does not convey sufficient air 
to them. In reference to the situation, we assume, that those 
have died last, to whose lungs the access of air was in some 
degree possible. 

But the possibility of obtaining respirable air, depends often 
on very different and apparently opposite circumstances. In 

a conflagration which broke out in this city ( ) 

in 1808, two persons by the ruins falling down before the door 
of the cellar, were enclosed therein. One was an old man of 
seventy, and asthmatic, the other a very healthy person, aged 
about forty. The latter stood upright, and was near suffocat- 
ing, in consequence of a fine smoke, which penetrated into 
the cellar and filled the upper half thereof; the old man, on 
the contrary, who had sat down on the floor, experienced 
nothing af this inconvenience. A man, who with his daught- 



354 



Presumption of Survivorship. 



ers and his mother aged seventy, retired into a cellar, on ac- 
count of fire, was suffocated with his children; while his aged 
mother was taken out the next day, half dead, gasping for air, 
but recovered and lived some years thereafter. 

The nature of the masses which cause the entombment 
produce various effects, while the wounds depend on the mas- 
ses causing them, the height from which they fall, and also 
the position in which the injured parts are. If large and 
heavy masses, ruins of walls, rocks, beams, stones, &c., fall 
upon the body, although the external wound may not appear 
severe, yet on dissection, we shall find the large blood-vessels, 
and the heart itself lacerated, and as the extravasated blood 
stains the parts, it is very difficult to decide whether the liv- 
ing man or his recent corpse was injured. Yet in the last 
case, the countenance is composed, or certainly not so dis- 
torted, as when a man has died in great terror and pain, and 
receiving very severe wounds. 

Masses which do not cohere together, as earth, sand, rub- 
bish, &c., press together the injured parts heavily, without 
generally breaking them. They also separate the extremities 
from the trunk, while they press on the space between, as, for 
e-xample, between the arms and body. In the case of a 
female overwhelmed in a sand-pit, I found the body so much 
compressed, that it had scarcely half its natural thickness; 
besides this, however, there was no external injury observa- 
ble. Occasionally portions of the falling masses press upon 
the openings of the softer parts, as in the eyelids, mouth, &c. 
The abdomen will be pressed together, and the contents of the 
intestines and bladder forced out, and sometimes even the 
contents of the stomach will be driven out through the mouth 
and nose. 

Should we find such persons in various situations and posi- 
tions, and in which it is evident that the deceased could not 
have been placed after death, as with the extremities drawn 
from the body, the arms upraised, or resting like the feet on 
the ground, or if we find under the finger nails, sand, &c., as 
if the sufferer had endeavored to extricate himself, or if some 
of these foreign substances are seen in the mouth and wind- 
pipe, it is beyond a question that such an one must have sur- 
vived another, on whom these marks are not found. 

It was remarked of those who were entombed by the earth- 
quake in Calabria, that the last position at the momonl of 
death, of males, was an exertion of all muscles, in apparent 
struggling; while that f»f the female sex exhibited n)aiks of 
the wildest despair. The latter, particularly, had their hands 



Presumption of Survivorship. 



355 



clasped above their heads. But when there were any chil- 
dren with the mother, she evidently thought only of protect- 
ing them, and with her own body endeavored to ward off the 
danger. The fatlier, on the contiary, seized his child and 
then opposed himself to it. Thus at Polestina, a mother with 
her two children, one a boy of three years old and the other 
an infant of seven months, was found. The infant was pressed 
to her breast, while her body was bent over the other, so 
as to oppose her back to the falling ruins. She held both chil- 
dren firmly inclosed within her arms, and in this position was 
found under the ruins. 

The following case was submitted for the opinion of Pyl. 
Two married persons had gone to bed in good health. The 
woman had, however, been lor some months feeble, and suf- 
fered frequently from faintness and headache. In the stove 
was found some charred oak wood, there was also an extin- 
guished lamp in the room, but no smoke or vapour could be 
discovered, although the ventilator was closed. 

Both were found dead, and as was supposed, from the fumes 
of charcoal. The relatives raised a suit about the estate. 
Those of the husband contended that he must have survived, 
as he was of a robust constitution, and thus resisted the dele- 
terious effects of the charcoal fumes longer than his feeble 
wife. Besides, his body was found warm in bed, while hers 
was cold. On the other hand, the friends of the wife object- 
ed, that it was not by any means certain that in all cases the 
weaker would yield sooner than the stronger. The body of 
the husband was probably covered with the bed-clothes, and 
thus preserved its heat, whilst it was ascertained that that of 
the female was naked. They relied, however, principally on 
the fact that the wife was only 20 years old and the husband 
21, and hence she, as the younger, must have survived. 

The following were the appearances externally and on dis- 
section. Both were found in the bed, the woman with folded 
hands, and body stretched out upon her back, while from the 
mouth issued a very fetid and rather bloody froth; and from 
the parts of generation light red blood, which also stained the 
bed-clothes. The husband lay near her also stretched out, 
but the upper extremities were stiffer, and his fingers drawn 
together convulsively. A blackish froth issued from his 
mouth. All the depending parts of the body in each was of 
a black and blue color, but in neither could any mark of 
wound or injury be discovered. The color of putrefaction 
was present, but the outer skin was firm. 

On the dissection of the female, the abdomen was found 



356 Presumption of Survivorship. 



greatly distended; the intestines exhibited some livid spots; 
the stomach was much enlarged, its upper part inflamed and 
the blood-vessels swollen, while the inner surface contained 
large black spots of the size of a dollar, on which the villous 
coat was abraded. The impregnated uterus was inflamed on 
its surface. The lungs were pale and collapsed, and in them 
and in the heart the blood was small in quantity, but frothy, 
black, and fluid. The blood-vessels of the brain were greatly 
distended with black, thin blood. 

In the husband the appearances were similar, but more 
marked. There was more serum in the abdomen, and the 
stomach was more inflamed. The liver dark colored, con- 
tained much fluid, frothy blood. The lungs were more swol- 
len, here and there discolored, and the vessels full of blood. 
The heart contained more blood than in the female, but the 
condition of the brain was very similar. 

The opinion of Pyl is to the following effect: While all 
cases of this description are extremely perplexing, and it is 
indeed impossible to arrive at a conclusion with absolute cer- 
tainty, the difficulty is here increased by the fact that the 
period of death in these persons is imcertain, and that both, 
when found, were already stiff' and cold. Their appearance 
was that of ordinary sleep, neither their countenance nor their 
limbs were distorted, and it is hence highly probable that 
both were deprived of life at the same instant. They were 
^ apparently suffocated during sleep, or otherwise we should 
have noticed some indication of an attempt to restore them- 
selves. A few minutes at the most could have intervened be- 
tween their deaths, and from the examination, it would appear 
that the effects on the husband were the most rapid and decis- 
ive, as shown by the state of the heart and lungs. Still, as 
the woman was the weakest, and was subject to faintings, she 
may have died first. Jn fine, it is impossible to answer the 
question in a positive manner. 

Our author objects to this indecision, and remarks that Pyl 
should have made a distinction between the various effects of 
the fumes of charcoal, as they either first attack the brain and 
cause faintness and apoplexy, or else suffocation (choking 
rheum). Now, on the body of the wife, no marks of the lat- 
ter were discovered, whilst they were on that of the husband, 
and the probability therefore is tbat the wife died first. 

Metzger has also noticed this case, and declares that he would 
have decided for the earlier death of the wife. — Amer. Journ. 
Med. Scien., from Wildberg^s Jalirbuck der Gesammten Staats- 
arzneikunde, 

{To be continued.) 



Poisoning by Snails^ — ElectrO'Magnelism. 



357 



Poisoning by Sneils. — A family of peasants living in the 
commune of Clermont, near Toulouse, fell a sacrifice to poi- 
soning by snails. The physician who attended them commu- 
nicated the details to the 'Journal de Toulouse:' — 'From what 
I collected concerning the circumstances which preceded the 
disease, and those which accompanied it, and from the symp- 
toms which I myself witnessed, 1 liad no difficulty in recog- 
nizing a case of poisoning like those occasioned by narcotico- 
acrid vegetables, such as belladonna, hyoscyamus, thorn- 
apple, No doubt remained in my mind as to the cause 
of this terrible disease, as soon as I knew that the snails eaten 
had been collected in the bushes called in French redout, but 
in the patois of the country, roudout. Everyone knows that 
the leaves and young shoots are a poison to the domestic ani- 
mals which browse on them, and that they kill them, after 
causing giddiness, and a kind of epileptic attack; but a fact 
which is not known is, that the flesh of these animals may 
occasion the greatest danger, and even death itself. Symp- 
toms like those which I have just witnessed are rare; but it is 
common to see among our peasants indisposition caused by 
snails, which comes from their eating them as soon as they 
are gathered. The example of the ancient Romans should 
be followed, and these animals should not be brought to table 
until they have been kept six months or a year, ieeding them 
with bran and wild thyme. This is the way also to make 
them fatter and more savory. — New York Lancet^ from Ga- 
xette Medicah, 



Electro- Magnetism in a Case of Poisoning, voith Sugges- 
tions for its application to stiU-born Children, and some forms 
vf Disease. — By Thomas S. Page, M.D., of Valparaiso. — A. 
T., an Englishman, the subject of this communication, aged 
Iwenty-tvvo years, and of robust frame, is a clerk in one of 
ihe most respectable commercial houses in Valparaiso. He 
had a slight gleet, for which he prescribed himself pulverised 
cubebs of doses of half an ounce, night and morning, and ex- 
perienced from them neither good nor bad effects. On the 
night of the 16th of March, 1842, he went to an apothecary's 
shop and asked for cubebs. Not having confidence in the lad 
in attendance, he requested permission to examine the label 
on the bottle, and read thereon "Pulv. Cubeb." He then 
ordered an ounce, divided into two parts, and with these re- 
turned home at midnight. He immediately took one of the 
4 



358 



Electro- Magnetism in Poisoning, 



powders, placed himself in bed, and, as was his custom, took 
up a book to read, but, as he expresses it, had not read two 
lines before he felt a dizziness and inclination to sleep. I ac- 
cidentally discovered him the following morniiig about twelve 
o'clock with these symptoms: face red and swollen; lips dark- 
purple; mouth containing a viscid frothy saliva; tongue has a 
dry and chapped appearance in the centre, and the teeth are 
slightly coated with a brown sordes; veins of the forehead 
and temples turgid; eyes rolled upwards, injected, and their 
pupils contracted to a point; skin moderately warm and 
moist, with clammy perspiration; feet cool; pulse very slow, 
moderately full, and dispersed by the least pressure; respira- 
tion very slow, short, and gasping. By agitating him violently 
he was aroused for a moment, uttered some incoherent ex- 
pressions, and sank back into comatose sleep. 

These were the symptoms when I first saw him. Dr. Hous- 
ton of the Royal Navy, now practising in this place, and Dr. 
Barrabino, of the U. S. Navy, then attached to the U. S. 
schooner. Shark, came to my assistance. We administered 
the sulphate of zinc as an emetic, and hot mustard and water 
to arouse tlie sensibilities of the stomach to its impression. 
Large draughts of this, and tilillation of the fauces, produced 
vomiting, and a small quantity of the powder apparently was 
brought up. The stomach pump was at hand, but as vomit- 
ing was readily piovoked, it was not used. The patient was 
made to sit on the edge of the bed with his feet hanging in a 
tub of almost boiling water strongly charged with mustard. 
One cup was applied to each temple, and about two ounces of 
blood abstracted. Large sinapisms were spread over the chest 
and stomach and inner parts of the thighs. A very strong 
liniment ol ammonia, cantharides, and turpentine, was applied 
to the whole length of the spinal column, until the skin be- 
came very red and inflamed. When the stomach seemed to 
be cleared of all traces of the poison, the mustard dr.iught 
was suspended, and a large quantity of olive, with castor oil, 
administered, but only a part remained. The patient now 
appeared to be sinking. The surface was cold and covered 
with a damp sweat; the face was pallid, with a purplish 
tinge; the jaw and eyelids were fallen, when the patient, by 
powerful sternutatories and severe blows on the j'ace and 
.shoulders with the open hand, was with difficulty made to 
rise. Ammonia and brandy and water were now given, with 
light broths, and an injection composed of turpentine and 
ammonia. This produced a slight discharge from the bowels. 
The stimulating liniment already mentioned was repeated to 



Electro- Magnetism in Poisoning. 359 



the spine and over the surface of the body. The puise was 
hardly perceptible at the wrists, if, at times, it was at all to 
be felt. The stimulants were continued. 

It was now 3 p. m. There were no si<;ns of reaction, and 
the features wore the aspect of death. Under these discour- 
aging circumstances, and when every effort seemed vainly ex- 
pended, we now determined to dress the patient and support- 
ed by two strong assistants, to take him from his room, con- 
tinue the stimulants and light broths, and endeavor to walk 
him in the cool air. At first he made feeble but unsuccessful 
efforts to direct the movements of his legs, but at length 
could not be aroused, made no effort to stand, and sank almost 
lifeless into the ai'ms of his assistants.* He was carried to 
his room and placed in a slightly reclining posture on his bed. 
His breathing was now short and hurried; his mouth wide 
extended and jaw fallen; nothing seemed capable of arousing 
him; the exhaustion was extreme; the pulse could be felt 
feebly at the wrist, maintained there probably by the agita- 
tion which he had just undergone. Dr. Houstoua had left at 
a short time previous, Dr. Barrabino remained with me. 

It was now 4 p. m., and worn out with fruitless efforts we 
desisted entirely from farther exertion. At this conjuncture 
I thought of my electro-magnetic battery, and proposed its 
application to bring about reaction, for I felt we were justi- 
fied in such desponding circumstances to make it a matter of 
experiment. Cerebral congestion was urged as an objection, 
but admitted not to be sufficient, in such a desperate case, to 
set aside the experiment. It was immediately tried, and with 
the happiest results. With an assistant rapidly rotating the 
wheel, I applied the balls at first to each side of the neck, and 
ran them down behind the clavicles. The arms and body 
now moved convulsively, but the patient lay as unconscious 
as before. I now passed one ball over the region of the heart, 
and the other to a corresponding point on the right side. In 
an instant his eyes opened widely, and with a ghastly expres- 
sion of countenance; his head and-body were thrown convul- 
sively towards me, and he groaned. He now sank back into 
his reclining posture, and he was again asleep. The balls 
were re-applied in the same situation with similar results — a 
third and fourth time, and he cried, "No more.'' Reaction 
was now positively established; the heart had received a 



* Broths and stimulants were poured into his mouth, but he coukl no longer 
s wallow them. 



360 



Electro- Magnetism in Poisoning. 



strong impulse; the pulse was becoming rapidly developed, 
and the whole surface warm. 

We now determined to desist, and watching him atten- 
tively, allow him to remain quiet for an hour. Reaction con- 
tinued satisfactorily, and when the hour had expired he could 
be awaked by shaking his body and calling loudly his name. 
There was no further occasion for the battery. He was 
aroused at intervals; and at eleven o'clock in the evening was 
sufficiently awake to relate where he had got the medicine 
the preceding night, but was still drowsy, and when not dis- 
turbed inclined to sleep. Thus he passed the night, and on 
the following morning was pretty well. He then told me 
that he had heard many things the preceding day that were 
said by persons about him, but he neither felt the power to 
open his eyes nor move his tongue to speak, although up to 3 
p. m., when powerfully agitated and spoken to, he would re- 
ply in short and sometimes broken sentences, and occasion- 
ally correctly. He further says that the last thing he has any 
recollection of was my remark, whilst they were attempting 
to walk in the corridor, that nothing more could be done but 
to make the experiment. From that time all was blank to 
him, until, as he expressed it, "he felt as if a gun had been 
fired off' within him, which thrilled through and shook him to 
the very extremities." This was the application and effect of 
the electro-magnetic battery. 

I have said that cerebral congestion was thought at the 
time to make the application of the battery in such cases ob- 
jectionable. The result proved the incorrectness of this opin- 
ion, and sustains this argument in favor of the practice adopt- 
ed, viz: — By observing the phenomena of diseases a relation 
may be remarked between some of them in their earlier 
stages, whose terminations and consequences are quite dissim- 
ilar; apoplexy and epilepsy furnish an example. In both 
there is great cerebral congestion. The former generally 
terminates in effusion, and paralysis is the consequence; the 
latter terminates in spasms, and the patient returns to his 
usual health. Therefore it would seem that the muscular 
spasms equalise the circulation, and thus unload the brain; or, 
if we might suppose epilepsy to depend upon a determination, 
if I may use the expression, of the nervous principle to the 
nervous centres, the latter are relieved by throwing it off 
upon the nervous extremities, occasioning thereby spasm. 
Viewing these vital actions as the efforts of nature to relieve 
organs from the effects of undue accumulation, and restore 



Electro-Mag neiism in Poisoning. 361 



the equilibrium in the nervous and vascular systems, it ap- 
pears probable that severe narcotism of (he nervous centres 
may be diffused and shaken off by the revulsive action of the 
battery on the nervous branches, and that the consequent 
developments of vital action would give an impulse to the 
general circulation which might relieve the cerebral conges- 
tion. 

A question might arise as to the power of the medicine 
taken to destroy life. On this point the melancholy death of 
Mr. C, a French gentleman, late of this place, who took the 
same medicine and in the same quantity but a few weeks 
previous, affords convincing testimony. In illustration of my 
subject I asked Dr. Cazentree, a French practitioner of this 
place, and the physician of Mr. C, for an account of the cir- 
cumstances attending his death, and the autopsy, which he 
very politely communicated as follows: — 

"Mr. C. was afflicted for some time with a gonorrhoea, for 
which, without medical advice, he took balsam copaiva, even 
in large doses, but to no etlect. He was now attacked with 
orchitis, and for the first time came to consult me. After 
eight days of constant attendance the swelling which existed 
in the left testicle disappeared, but the blenorrhagia returned 
with more force. Vexed with this he again wished to take 
remedies which might relieve him at once of this alBicting 
disease. I recommended the use of the cubebs, which, taken 
for nine days, and gradually augmented to two drachms three 
times a day, had almost completely taken away this obstinate 
affection, when, on the 13lh of February, not having any of 
the remedy left, he sent the same recipe to the nearest apoth- 
ecary's shop.* At ten o'clock at night he retired to his bed- 
chamber well and cheerful. Without consulting any one, on 
lying down he took half an ounce of cubebs. No noise what- 
ever was heard during the night, and at seven o'clock the fol- 
lowing morning, when they entered his bed cliamber, they 
found him in a slate of insensibility. Half an hour after I 
was with him, assisted by Dr. Yeillon, and we found him in 
the following condition: — 

"The body is in a state of supination; all the senses are ex- 
tinguished, without hearing, speech, or movement; the eyelids 
are fallen, and when raised the eyes look cloudy and fixed; 
the pupils are dilated; extremities llexiblo; they obey the 
hand which raises them, and fall like an inert body; heat nat- 



* He had previously got the cnhcbs at another shop, but on this occasion pur- 
chased it at the same shop where my patient subsequently jirocured his. 

4 * 



362 



Electro-Magnetism in Poisoning. 



ural and equally diffused; face red; there are colored, blackish 
spots on various parts of the body, but principally on the 
back; when the body is nnoved a species of strong rale is 
heard in the bronchia; pulse slow, feeble, and very irregular; 
respiration hardly perceptible. Not knowing to what to 
attribute a state so suddenly produced and so grave, and re- 
cognising by the symptoms the appearance of asphyxia, and 
thinking he might have taken too stroog a dose of the medi- 
cine. Dr. Veillon and myself proceeded in consequence to ex- 
tract from the stomach the cubeb that it might yet contain, 
and to cause reaction by the most powerful excitants. But 
all was in vain, and at twelve (noon) life was completely ex- 
tinct. Nothing now remained but to make the autopsy, 
which we did the following morning at seven o'clock. All 
the cavities and organs were examined with the greatest 
care. 

"Exterior. — The face is pallid, the integuments livid, prin- 
cipally behind, and the corpse rigid. 

"Abdomen. — The stomach with no trace of inflammation, 
contains a tumblerful of liquid, in which is observed a little of 
the powdered cubebs, mixed with some aliment, which is 
almost digested; the intestines are sound and healthy; the 
bladder is full of crystalline urine; the liver, spleen, and kid- 
neys are full of black and fluid blood. 

"Thorax. — The lungs are excessively engorged with blood, 
and when cut into with the knife this flows with a great 
abundance of froth from the bronchia; the left side of the 
heart is entirely empty, the right full of blood; the aorta and 
all the arterial system is entirely empty; the venous system 
of the thorax and abdomen, as well as the pulmonary artery, 
the vena cava and portal, are full of i)lack and fluid blood, 
which flows abundantly as soon as the vessels are divided. 

"Head. — The veins of the brain are also congested, but the 
congestion of this organ is not as great as that observed in 
the thoracic and abdominal viscera. I repent, that in no part 
was there red or coagulated blood found, but always black 
and fluid, and filling all that appertained to the venous sys- 
tem.'' 

Before closing this subject,! would beg leave to adJ my im- 
pression that electro-magnetism will not only be found a most 
useful agent in cases like the above, but in some forms of dis- 
ease, particularly those of a highly congestive character, 
where oppression of the organs and the nervous system pre- 
vent reaction and speedily destroy life. I need not occupy 
space in adducing cases illustrative of my meaning. In prac- 



Electro- Magnetism in Poisoning. 



363 



tice I think we frequently see cases where death seems to be 
caused by an obstruction of the functions or organic move- 
ments which support hfe. more than by an exhaustion of the 
organic functions or of Hfe itself. And in such cases electro- 
magnetism might communicate an impulse which would renew 
those sympathetic actions between the organs (if no positive 
lesion exist in any of them) upon which the continuance of 
life depends. 

In all cases of asphyxia, electro-magnetism must be useful; 
and I am strongly impressed with the belief thai it might be 
applied in very many instances to still-born children with the 
happiest effects; for this purpose an instrument might be used 
of a very portable form, — tliat used by me in the case related 
consists of a large horse-shoe magnet, mounted upon a stand, 
in a vertical position, with an armature, fixed upon an axis 
between the poles, so as to revolve in front by means of a 
wheel. The armature consists of two cylindrical bars of soft 
iron, connected by a cross-bar, and in the centre of the bar is 
an insulated ferule; as near the end of the bar as possible is 
fastened the "brcakpiece." Around each of the cylindrical 
bars is wound two thousand two hundred and fifty feet of wire, 
covered with cotton thread, to prevent the current of electri- 
city from passing from one wire to the other; the end of one 
of the coils is connected with the "breakpiece,''^ and the other 
with the ferule. From one of the pillars, which are in front of 
the armature, the springs are made to act on the ferule and 
breakpiece. Fiom the otlier pillar the spring connects with 
the centre; the handles are fastened by the set screws in the 
base of the pillars. 'J'here are four set screws in the back of 
the upright l)lock of wood to set out the magnet, so as to 
make the armature revolve as close as possible to the magnet. 
The shock is communicated on ordinary occasions by grasping 
large biass handles which connect with the instrutnent by 
short coils of wire, which are painted red. To apply it to 
different parts of the body long wires, covered with colton- 
ihread, and terminating in brass balls, are used. Two glass 
cylinders enclose the wire near the balls, for the operator to 
hold by while administering the shock. 

The above article, which we copy from the London Lancet, 
is also published in the American Journal of the Medical 
Sciences, for April, just received. Dr. J. Warrington, through 
whom it was transmitted to the latter Journal, received at the 
same time two parcels, one containing the half-ounce of 



364 Electro-Magnetism in Poisoning. 



powder corresponding to that taken by the patient; the other 
a substance purporting to be cubebs, and bought at the same 
shop. These were given to Mr. Procter, Jr., for examination; 
he publishes an analysis of them in the American Journal, 
from which we copy so much as will show the nature of the 
deleterious substance. 

The substance submitted for investigation consisted of two 
specimens; one labeled "sample of the powder correspond- 
ing to that which the patient took;" the other, "sample of the 
powder purchased by Mr. Peel whilst the patient was under 
the influence of the poison, -who at my suggestion, went to 
the same shop and asked for an ounce of pulv. cubebs." 
They were severally enveloped in double papers and sealed; 
the first weighing about 100 grains, the second 200 grains; 
and their sensible properties accorded in all particulars. 

The powder was dry, finer than cubebs ordinarily occur, 
and without the moist appearance usual to it. Its color was 
a uniform brown, its odour less aromatic and agreeable than 
that of good cubebs, and its taste pungent, though accompa- 
nied by a bitterness not found in the genuine drug. 

In the paper accompanying the specimens, Dr. Page does 
not express an opinion as to the nature of the poisonous agent 
associated with llic cubobs. A consideration of his remarks 
on the symptoms produced by the powder, suggested the idea 
that opium mixed with cubebs might produce all the effects 
there detailed. The sensible properties of the substance sus- 
tained this impression, and the addition of tannic acid and a 
persalt of iron to its decoction giving indications favorable 
to the presence of morphia and rneconic acid, was consid- 
ered sufficiently encouraging to cause a pursuit of the investi- 
gation with a view to the presence of opium. 

The following is a summary of the substances isolated. 



In 100 parts. 



Cubebin or pipcrin, 
Morpliia, 
Meconic acid, 
Narcotine, 
Narccia, 

Volatile oil and resin. 
Extractive and gum, 
Chloride of sodium, 
Lignin, 



2.2,5 
2.50 
1.23 



J 



Proportions not ascertained. 



Researches on Digestion. 



365 



As the object of this analysis is to ascertain the nature and 
properties of the deleterious agent associated with the cubebs, 
only those parts of the investigation have been given in detail, 
which, by proving the presence of morphia and rneconic acid 
in the powder, render the existence of opium in it evident. 
That other principles, as codeia, meconin, etc., were also 
contained in it, there cannot be a doubt, but search for them 
would be as hopeless as it is useless. In conclusion, it may 
be observed that the quantities of morphia and rneconic acid 
indicate the presence of about 30 per cent., of opium in the 
powder, equal to 75 grains in the dose taken by the patient, 
and doubtless sufficient to have occasioned death. 



Researches on Digestion. — By Bouchardat and Sandras. 
By feeding dogs with pure fibre, killing tlietn at different in- 
tervals after taking the food, and examining carefully the con- 
tents of the stomach, intestines, and the chyle itself, and com- 
paring them with the appearances presented in dogs killed 
while fasting, Bouchardat and Sandras have arrived at re- 
sults which, while opposed to the usual belief of the physi- 
ology of digestion, seem to bear out the conclusions drawn 
by the illustrious experimentalists. Thoy found that the fibrin 
was converted into a fluid in the stomach, was in fact dis- 
solved. They found that the fluid did not pass into the intes- 
tines, or but a very small portion only, that all the truly dis- 
solved matters were removed like other fluids from the sto- 
mach itself. That the matters which were found in the intes- 
tines of the animal killed when fasting were identically the 
same as those of the animal fed with a full meal of pure fil)rin, 
only the latter contained a slightly greater proportion of fibrin 
in a dissolved or fluid state. The chyle, too, of the fasting^ 
animal presented the exact same qualities as that of the ani- 
mal which had a full meal of fibrin, the proportion of dissolved 
fibrin in it was only very slightly greater. 

It was found that the solution of the fibrin in the stomach 
took place by means of hydrochloric acid, and that the same 
process could be imitated out of the body by mixing a quan- 
tity of hydrochloric acid, so small as scarcely to aiTect litmus 
paper, in distilled water, and immersing in it a morsel of 
fibrin. After twelve hours, at the the ordinary temperature, 
the fibrin was found converted into a gelatinous mass, which, 
if dissolved in distilled water and filtered, could not be recog- 
nized to diflfer in any chemical character from the fibrin found 



366 



Researches on Digestion. 



dissolved in the stomach of the dog. These experimentalists, 
therefore, regard the hydrochloric acid as the essential agent in 
< the solution of the fibrin; and as the experiments of Halle, Ma- 
gendie,and other physiologists prove, that alcohol and other flu- 
ids, colored and uncolored, are removed directly from the stom- 
ach by means oftlie venous system, and cannot be recognized in 
the chyle while their presence can be detected in the blood, Bou- 
chardat and Sandras have no hesitation in stating, as the re- 
sult of their observation, that the same takes place with the 
fibrin after it has once become dissolved. 

They performed analogous experiments on dogs with glulen, 
and found the very same results were arrived at. It formed 
a solution in the stomach precisely similar to that of fibrin; 
was removed from the stomach in the same manner, without 
passing into the intestines in any appreciable quantity: and 
dissolved out of the body by means of water slightly acidu- 
lated with hydrochloric acid. Albumen and pure caseum 
underwent solution in diluted hydrochloric acid in the same 
manner, and furnished the very same reactions with chemical 
agents. 

A number of other experiments were made on the digestion 
of starch, sugar, (fee, from which it appeared that these sub- 
stances all became converted in the stomach into lactic acid, 
and were removed from it directly in the same manner as the 
dissolved fibrin, gluten, &c., had been. The chyle of animals 
fed with these non-azotized matters yielded no traces of starch 
and scarcely any of acid. In all animals the chyle was alka- 
line, or quite neutral. When dogs are fed on substances 
which they loathed, and would have vomited were the oeso- 
phagus not tied, the chyle was neutral, but when fed on bread 
or potatoes was always alkaline. 

Experiments were also made on feeding dogs with fat. It 
was found that this substance was not altered in properties in 
the stomach, as pure lat was obtained from the pultaceous 
mass. The other liquids present in the stomach were acid, 
and contained hydrochloric acid. In the duodenum a yellow- 
ish-colored emulsive mixture was found, with a neutral reac- 
tion, which yielded fat when washed with ether. The other 
small intestines contained also a similar matter which lur- 
nished fat to ether. The thoracic duct furnished a white 
milky-looking chyle, much whiter than was ever seen in the 
former experiments, and when washed in ether furnished a 
notable quantity of fat. 

These experiments seemed to prove that fat is digested in 
a very diflerent way frorn the other nutritive matters; that it 



Researches on Digestion. 



367 



undergoes no change in the stomach, but that its chief changes 
occur in the duodenum; that, in fact, those changes occurred 
to it there whicli facilitated its absorption. Tiiese changes are, 
however, very simple. The pancreatic fluid and the bile mix- 
ing with the fatty matters, iorrn a simple emulsion, without 
changing the chemical nature of the fatty matters. If these 
contain margaric and oleic acids in their natural state, they 
are saturated by the alkali contained in the pancreatic juice 
and in the bile. In this state they are absorbed by the orifi- 
ces of the chyliferous vessels, and from thence carried into 
the thoracic duct, and mixed with the chyle. The analysis of 
the chyle proves this fact, and the examination of the con- 
tents of the bowels, at all parts of their course, prove that 
they contain fatty matters, which, if given in too large quan- 
tity, are even excreted with the feculent matters. 

Bouchardat and .Sandras draw the following important con- 
clusions from their experiments: — 

1. In digestion, the functions of the stomach consist in dis- 
solving with the aid of hydrochloric acid, all albuminous mat- 
ters, as fibrin, albumen, caseum, and gluten. 

2. This acid, if diluted with 5000 parts of water, dissolves 
the same matters out of the body, provided they are not 
cooked; but if boiled the solution has no action on them. As 
they are found to be dissolved, however, in the stomach, it is 
probable that some other agent is at work than simple solu- 
tion by means of hydrochloric acid: but the presence of that 
acid seems to be always indispensable. 

3. As far as the albuminous matters are concerned, diges- 
tion and absorption take place exclusively in the stomach; the 
intestines present scarcely any traces of those dissolved mat- 
ters which exist in such abundance in the stomach. 

4. Solution of fecula also occurs in the stomach. This 
principle does not appear to pass into the state of sugar, and 
the experiments do not even warrant the statement that it 
passes into that of soluble starch; we regard as proved, its 
transformation into lactic acid. 

5. The absor])tion of this kind of aliment seems to take 
place less exclusively from the stomach than that of the albu- 
minous matters, a circumstance which would accord with the 
particular disposition and length of the intestines in animals 
not carnivorous. 

6. Fatty matters are not attacked in the stomach. They 
pass into the duodenum in a state of emulsion, in conse- 
quence of the alkalies furnished by the liver and pancreas. 



368 Treatment of Pneumonia in Guy^s Hospital. 



This emulsion is found abundantly throughout thewhole course 
of the intestines. 

7. The chyle has appeared to be somewhat less abundant, 
but presenting similar characters in the animals which were 
killed after long fasting, and in those killed after being fed on 
copious meals of albuminous matters and of fecula. It has 
only presented a marked difference in those fed with fat, 
when this principle was met with in it in considerable pro- 
portion. 

Differing as these views do from those at present in vogue 
relative to digestion, Bouchardat and Sanclras add a few re- 
marks on the peculiarity of their views and the probable use 
of the chylifei'ous system of vessels. It is to be remembered 
that they found that the chyle procured during the digestion 
of fibrin did not difler in a single character from that pro- 
cured from an animal fed on fecula alone, or in a state of 
starvation. That, in fact, these matters had not been con- 
verted into chyle. One important fact they ascertained to 
be was, that these chyliferous vessels absorbed the fatty mat- 
ter, but this cannot be their sole use. During digestion a 
large quantity of hydrociiloric and lactic acids are secreted 
and thrown into the stomach. These acids must come from 
the decomposition of salts existing in the system — chloride of 
sodium and lactate of soda. Tiie abdominal glands prepare 
for the chyliferous vessels and thoracic canal, a chyle, the 
alkalininity of which is greater in proportion to the acidity- 
developed in the stomach; and thus cliyle, which is not solely 
produced by the absorption of aliments, but by a process of 
true secretion, mixes with the blood, to neutralize the acid 
which was indispensable lor the solution of the food in the 
stomach. This simple process allows the blood to be continu- 
ally repaired, without appreciably changing its nature. — An' 
nales des Sciences Naturelles, October, 1842. Bulletin Med. 
Sci. 



The Treatment of Pneumonia in Guy's Hospital. — The pure 
Aniimonial ewe. — No one mode of treatment should be 
adopted in pneumonia. To say that venesection, twice or 
thrice repeated, or antimony, or calomel and opium, should 
always be the remedy, would be dangerous in practice. If 
the disease existed always in persons of the same habits, coun- 
try, and locality; was always presented in the same stage, 



Treatment of Pneumonia in Guy^s Hospital. 369 



uncomplicated (and so on), then one treatment might be 
adopted with advantage; and tables, showing the cures and 
deaths, from one or the other mode, might be trusted as 
guides. But each case should be more or less studied by it- 
self. I shall presently have to recommend moderate vene- 
section, followed by calomel, opium, and antimony; but a 
young man was admitted into Guy's hospital a few weeks ago 
suffering from pneumonia, passing to the second stage: no in- 
dication of tubercles could be discovered; he had no typhoid 
symptoms; but he was so feeble that bleeding would have 
killed him, or antimony would, I believe, have extinguished 
life. He was treated for the first twenty-four hours with am- 
monia; after which he was ordered in a pill, — two grains of 
blue-pill, two of extract of hyoscyamous, and one of ipecacu- 
anha, — and a draught composed of ten minims of liquor po- 
tassae and an ounce and a half of decoction of bark, every six 
hours; a blister to the side, and mild nutritious diet. It is 
true that a few days after, when he had improved in power, 
he was put upon calomel and opium, and antimony; but these 
were withdrawn in two days. He then had merely a little 
saline medicine, followed by quinine; blisters to the affected 
side were several times repeated during the period, and he 
left the hospital in a few weeks, cured of his inflammatory 
complaint, though still weak. He will probably ultimately 
die of phthisis. 

In the average of cases in this hospital a considerably lar- 
ger proportion ol those who were bled recovered, than of 
those who were not. But that venesection is therefore ad- 
vantageous in pneumonia, abstractedly considered, could not 
be fairly supported, as venesection was, I believe, practised in 
all cases, excepting m those who were already too much de- 
bilitated, or too slighly aflected. 

The plan for many years generally adopted in Guy's Hos- 
pital, in acute fmeuiTioiiia, has been to bleed the patient to ap- 
proachmg syncope, and to administer a pill, containing half a 
grain of opium, and a quarter of a grain of tartarised anti- 
mony with one or two grains of calomel, every three, four, 
or six hours, according to the severity of the symptoms, usu- 
ally combined with a saline mixture, containing twenty or 
thirty minims of antinionial wine. If, in a few hours, or next 
day, the general symptoms have been unsubdued, or have re- 
turned, venesection has been repeated. It has sometimes 
been necessary to bleed again and again. Triple venesections 
have been uncommon, and a fourth very rare. If the general 
symptoms, on the contrary, have been reduced, though the 



370 Treatment of Pneumonia in Guy's Hospital. 

local affection has continued severe, or if the patient's power 
has been materially diminished by venesection, cupping has 
been ordered, to from six to twelve ounces. On a decrease 
of the disease, the medicines have been less frequently repeat- 
ed, or stopped, even though the mercury has not affected the 
mouth. If the system has evidently become affected thereby, 
but the complaint is still active, it has usually been discontin- 
ued, or repeated only in small unfrequent doses. Blisters also 
have been applied with good effect in the latter stages. The 
utility of the latter remedies has been doubted; but I state 
my thorough conviction of benefit being derived therefrom, 
in very many instances. The foregoing treatment has been, 
on the whole, so efficient that no important change has been 
considered justifiable. 

1 have frequently been desirous of trying the pure antimo- 
nial, or contra-stimulant, treatment; but in so important a dis- 
ease I have not felt justified in discarding means which have 
so often effected a cure. 1 must, however, confess that the 
results of the treatment of pneumonia in Guy's Hospital — if 
all cases, however advanced, and however complicated, be 
taken into account — are not to be compared with what are 
stated to have been the "triumphant" effects of antimony. 
Thus Laennec says, that of 62 cases treated by antimony, 
only 6 died, two being moribund on admission, two old men 
of seventy, with cerebral congestion and pleurisy, and the 
sixth under disease of the heart. Others are reported to have 
lost only 1 in 30 and 1 in 40 cases. However, my observa- 
tion is entirely opposed to Laennec, when he states that he 
has never known the disease renewed when antimony had 
effected amelioration. In the Infirmary of Edinburgh, while 
1 was a |)upil there, a patient after two venesections, leeches, 
and continued antimony, was considered almost convalescent. 
The antimonial solution was however continued. But when 
the disease had for four days appeared to be rapidly decreas- 
ing, the attack was renewed; and it was necessary again to 
bleed him to ten ounces, after which he rapidly recovered. 
The same has certainly happened in several cases that have 
fallen under my notice. In some instances, also, when anti- 
mony has been at first employed with benefit, but relapses 
have taken place, it has appeared necessary for the cure to 
administer calomel and opium in combination with it. Nev- 
ertheless, I believe antimony to be esjiecially useful in persons 
who cannot bear the abstraction of blood, and those in which 
mercury is contra-indicated. In such cases, as in the pneu- 
monia and bronchitis of children after measles, I have occa- 



Communication of Air Vesicles with Veins. 371 



sionally administered it, and with manifest advantage. The 
patients have, it is true, died from another complaint; but that 
complaint has been, I have thought, produced by the remedy 
employed for the pneumonia. 

The great authority last quoted considers antimony to be 
equally efficacious "in any stage of the disease, even after a 
great portion of the lung has undergone purulent infiltra- 
tion;" and supposes that it may act by "increasing the activity 
of interstitial absorption." But the well-known action of 
mercury in promoting the absorption of etiused matter, clear- 
ly points it out as the medicine especially indicated when 
there is inflammatory deposit. 

From the whole circumstances, I believe that antimony is 
a very active remedy in pneumonia, more particularly indica- 
ted in slight and recent cases, those complicated with bron- 
chitis, and those in which venesection cannot be borne or 
repeated, and mercury cannot be safely employed; that the 
cases are often more rapidly relieved by it than by any other 
means, but that they are also more than ordinarily liable to 
relapses; and that when consolidation has obviously occurred, 
it should not be trusted alone, but should always be given 
with mercury. — Dr. Hughes, Guy^s IIosp. Repl., October. — 
Lancet. 



Communication of Pulmonary Air Vesicles by a direct route 
with the Pulmonary Veins. By W. E. Horner, M. D., Prof, 
of Anatomy in the University of Pennsylvania. — The follow- 
ing experiments go to determine this point. 

Exp. I. In July last I lost a patient, James Roomy, tetat. 
19, at the Philadelphia Hospital, who had been treated by me 
for calculus of the bladder, by lithotrity. On the examina- 
tion of him after death finding the lungs in a state of perfect 
health, they were removed and taken to the University. I 
then fixed a pipe into the trachea and permitted a column of 
water to pass gently. The lungs filled up very completely, 
the air cells became distended with water, and somewhat to 
my surprise at the time, (for 1 had no such result in view, but 
merely to wash the lungs well for ulterior anatomical purpo- 
ses,) the left side of the heart filled and the aorta began to 
discharge water from its cut branches very freely, in fact in a 
strong jet when compression was made so as to reduce the 
size of the stream in its exit. 

No stream made its appearance from the right side of tin- 



372 Communication of Air Vesicles with Veins. 



heart, the water not showing any current in that direction, 
not even in drops, nor filling the pulmonary artery. 

These observations were repeated at several trials of a sep- 
arate kind on the same pair of lungs on the same occasion, 
and were renewed the next day. Tiie result was announced 
at the time to Dr. Samuel Jackson, my colleague as we were 
in consultation on a patient. 

Exp. II. In December last, a young athletic man lost both 
his legs from a railroad accident, followed by amputation. 
Having got his lungs with the heart attached,! renewed my 
experiments on the free communication of the air vesicles of 
the lungs with the pulmonary veins, and found the same re- 
sults from a column of water gently let into the trachea — the 
left side of the heart readily filled, and the branches of the 
aorta spouted out water. The pulmonary artery and the right 
side of the heart did not fill, but a little water after a while 
returned by them, not however in any approximation to the 
quantity discharged by the aorta. 

Exp. III. Feb. \Qtli. A Malay about thirty years of age, 
athletic and well formed, belonging to an East Indiaman, 
committed suicide about a fortnight ago. He stabbed himself 
in the abdomen so as to sever the colon and duodenum, and 
also opened the external carotid artery; by these several 
wounds he was well drained of blood. He was injected so 
as to retard putrefaction; the weather also has been highly 
favorable from its coldness, to the same end. The lungs to- 
day were in a state of perfect soundness, and of elegant nor- 
mal texture and colour, so that I exhibited to the anatomical 
class the best specimen of them in a state of exact physical 
soundness with freedom iVom congestion of blood, that I have 
met with in thirty years of anatomical pursuits. In the even- 
ing I injected the left lung according to my plan, with tallow, 
having in view the connection of the air vesicles with one 
another. 

On the 17th, I applied as in the two preceding experi- 
ments a column of water upon the lung of the right side. In 
a very little time I found the water returning by the pulmo- 
nary veins pleno rivo, and a very scanty show of it in the 
right pulmonary artery, not enough to discharge except by 
drops in a very slow manner. The experiment was renewed 
on several trials, and the results the same. 

It may here be remarked that the return of the fluid by the 
pulmonary veins was much more rapid in the beginning than 
towards the end of these experiments, for when the lungs be^ 



Communication of Air Vesicles with Veins. 



373 



come infiltrated with the water the connection of the air vesi- 
cles and the pulmonary veins is not so free. 

Exp. IV. Sept. 1842. On the lungs of a hog talien from a 
slaughter-house, the experiment done in the same way showed 
no communication either with pulmonary veins or arteries on 
the part of the air vesicles. 

Exp. V. On the lungs of a sheep, resulted in failing to 
show also any communication with the pulmonary arteries 
and veins on, the part of the air vesicles. 

Exp. VI. On the lungs of a calf, also failed to prove the 
communication between the air vesicles and the pulmonary 
blood-vessels. 

Among the venerable rites of that ancient people, the He- 
brews, is a scrupulous regard to the perfect healthiness of the 
flesh that they eat, and also to the animal when slaughtered 
having the blood almost thoroughly evacuated. At the sug- 
gestion of my friend, the editor of this Journal, I obtained 
the lungs of animals prepared for market by one of their 
butchers, and the following results occurred in the lungs of 
the calf and sheep. 

Feb. 25///. Exp. VII. On a calf. The lungs, upon the in- 
troduction of water into their air vesicles, began to return 
the water in a little time by the pulmonary veins and the 
pulmonary arteries. In keeping up the pressure of the 
column, it returned by a large free stream from l)olh sets of 
vessels. 

Exp. VIII. On a sheep. The lungs under the same regu- 
lated pressure of a column of water, returned it by the pul- 
monary arteries and v#ins also in a clear large stream. 

In neither animal, however, did it return with equal free- 
dom as in the human subject: though, in the lungs of the call', 
the stream was suflicientl}'' copious to wash back several large 
coai^iila of blood from the pulmonai v artery. 

The preceding experiments would go to prove the exis- 
tence of a direct communication between the air vesicles and 
the pulmonary blood-vessels, especially the veins. A sugges- 
tion to the contrary, which may have some force, is," that the 
connection, as above established, is not by direct inosculation, 
but by infiltration: to which it may be replied, that in such 
case the injected fiuid, by passing into the common connect- 
ing cellular substance, would constitute an intervesicular and 
interlobular dropsy, which would show itself by the water 
raising up the pleura in large vesications or bags — and by its 
■forming large interlobular collections — also by the incapacity 
of the lungs to contract to the normal size in a short lime. 



374 Communication of Air Vesicles with Veins. 

after the pressure of the water was withdrawn and the tra- 
chea left open. The lungs would at least remain for a time 
of a size nearly stationary on the suspension of the experi- 
ment, as in the carnification aiising from the large effusions 
of blood into its substance in violent pneumonia. Now if 
prudence be observed in the experiment, none of these events 
occur, but the lungs collapse almost as readily as if they had 
been distended simply with air. 

Exp. IX. On the fresh lungs of a large bullock. The resi- 
duary air of the pulmonary vesicles was, by the force of a 
column of water, driven from the lungs into the pulmonary 
blood-vessels, and the pulmonary artery was distended and 
inflated with the condensed air, so as to give it a tension and 
elasticity like that of a strongly inflated large intestine. 
With this state of things there was no emphysema of the 
lungs, which would follow inevitably without a direct com- 
munication between their air vesicles and the pulmonary 
vessels. 

In the same lungs the current of water sent into them 
through the trachea, returned so freely by the pulmonary 
artery as to make a jet six or eight inches long, and of the 
size of the little finger; it also came out in a free jetting stream 
from the branches at the arch of the aorta. These jets could 
be increased, diminished or stopped without delay by the 
turning of a stop-cock. 

Exp. X. On the lungs of a pig. I first of all inflated them 
by the pressure of a column of water acting on a reservoir of 
air. The air was found to pass readily to the heart by both 
pulmonary veins and arteries, but wilii especial freedom by 
the latter and distended them strongly. Having satisfied 
myself of this result, I then let in a column of water, which, 
as in the other experiments, returned freely by the pulmonary 
blood-vessels, being indicated by a bold stream from the pul- 
monary artery and aorta. 

The abundance of the |)ulmonary capillaries, and their thin- 
ness and superficial position may be considered as additional 
arguments in favor of the conclusion drawn above, of direct 
inosculation with the air vesicles, but of course by pores 
which must be exceedingly fine. The lateral pressure of a 
column of water upon them would, without such inosculation, 
have the effect of water in the bladder upon the ends of the 
ureters, and would prevent itself from getting into them. 

The foregoing experiments may serve to elucidate some of 
of the phenomena of respiration and of pulmonary liemor- 
rhage. 



Luxation of the Patella on its Axis. 



375 



The fact appears to be overlooked by pathologists gene- 
rally, that the bright color of the blood in htemoptysis, and 
the more superficial position and greater numbers of the pul- 
monary capillary veins, indicate that they are the true foun- 
tains of its blood instead of the arteries: — opinions which 
have for many years past been taught by me, on the ground 
of my minute injections of the lungs. 

I may also slate that with these experiments of the unques- 
tionable transmission of fluids and of air into the pulmonary 
vessels from the air vesicles, we can now account for what 
every experienced anatomist has often observed, and will in 
every case see, to some extent: that there is always air in the 
pulmonary artery, the left side of the heart, and the aorta, 
after death, however recent the death may have been, and 
also account for the mistake of the ancients that the arteries 
conveyed air naturally, inasmuch as ihey were found filled 
with it after death, an error which has been indefectibly com- 
memorated in the name of these tubes. 

As leisure otfers I propose to go on with the experiments 
on the above question of continuity between the blood-ves- 
sels and the vesicles of the lungs; but hope that in the mean 
time it may attract the inquiries of olh* is more competent to 
settle the precise mode ol this continuity. — Amer. Journ. of 
the Med. Sci. 



Luxation of the Patella on its axis. By Joseph P. Gaz- 
ZAM, M. D., of Pittsburg, Pa.— Sept. 10///, 1S42. This even- 
ing at 7 o'clock, James, aged 21 years, son of Judge Porter, 
of Pittsburg, was thrown while wrestling, and inunedrately 
found himself unable to rise. 

On seeing him about an hour after the accident, I found the 
patella of the right leg dislocated on its axis, i. e. it was lying 
on its edge — presenting the posterior face outward, and the 
anterior face inward— the inner edge resting in the groove 
between the condyles of the femur. 

Flexing the thigh on the pelvis and straightening the leg, 
I endeavored to replace the bone by pressing its edges in op- 
posite directions, but failing (after repoutcd trials) I requested 
that the patient should be brought to town, (the accident hap- 
pened three miles out of the city), and addilioncl advice pro- 
cured. 

At about 12 o'clock, the patient was brought to his father's 
house, where I met Dr. Addison. After repeated unsuccess- 



376 



Abnormal Nutrition. 



ful attempts at reduction, it was thought well to lessen the 
tension of the joint by dividing the ligament of the patella. 
This I did by introducing beneath the skin a narrow-bladed 
knife, and cutting the ligament close to the tubercle of the 
tibia. Again we attempted reduction but failed. The patella 
could be moved on its edge more freely than before the cut- 
ting, but resisted all our efforts to replace it. 

Dr. Speer was now joined to the consultation, and in ac- 
cordance with his suggestion the patient was placed erect, a 
vein opened, and the blood allowed to flow until the approach 
of syncope, when the efforts at reduction were renewed — but 
although the patella could be moved on its edge, it could not 
be lifted out of the groove in which it rested. It was now- 
agreed to let the patient rest for a few hours. 

llth. At 8 A. M. the consultation was resumed, and it was 
now proposed to adopt with some modification the plan of 
Dr. John Watson, of New York, as detailed in the N. Y. 
Journ. of Med. Surg. No. 2, and republished in the Am. 
Jour, of Med. Sciences, vol. 25, p. 262. 

The thigh was strongly flexed on the pelvis and the heel 
elevated. Then the leg was flexed steadily and forcibly on 
the thigh and suddenly straightened. At the moment of 
straightening the leg I pressed very strongly against the lower 
edge of the patella Irom without, with the head of a door key 
well wrapped, while Dr. Addison pressed with both thumbs 
against the upper edge of the bone towards the external con- 
dyle. On the fourth trial this manoeuvre succeeded, the bone 
springing into its place with a snap. A cushioned splint was 
placed behind the knee and secured by a bandage — an evapo- 
rating lotion was used, and the patient kept at rest. Recove- 
ry was uninterrupted, and the young,: man has now perfect 
command of the limb. 

To the inexperienced it may seem that I have attached 
undue importance to this case by reporting it for the medical 
public; but I have no fear that those who have encountered 
such a case will think it altogether valueless. — Amer. Journ. 
Med. Sci. 



On Abnormal Nutrition (commonly called Inflammation) , 
and on the mode in which its dij'eroit Products arc devel- 
oped, as Softening, Suppuration, Granulation, Reorganiza- 
tion of Tissue, Morbid Growths, (f'C. cf-c. — Dr. J. H. Ben- 
nett, in a communication read to the Medico Chirurgical 



Abnormal Nutrition. 



377 



Society of Edinburgh, commenced by alluding to the well- 
known fact, tliat the blood circulating to every part of the 
living organism, carried with it the principles of nutrition. 
These appear to exude through the minuter vessels dissolved 
in the liqujor sanguinis or blood plasma, which constituted a 
blastema or formative fluid for the formation of nucleated 
cells. The cells thus formed, underwent different kinds of 
development, some being formed into bone, others into mus- 
cle, nerve, tendon, filamentous tissue, and so on. The insen- 
sible formation and development of these cells constituted 
healthy nutrition. 

This process might be deranged, or rendered abnormal, in 
various ways: 1st, from an increase or diminution in the 
whole mass of the blood; 2dlij, from a greater or less change 
in the relative amount of its diflferent chemical constituents; 
and, 3dty, from mechanical and other causes acting more 
especially upon any part of the frame. It was to the phe- 
nomena accompanying the latter condition that Dr. Bennett 
was desirous of directing the Society's attention. These 
were rapidly described, as they have been observed by numer- 
ous authors, and confirmed by Dr. Bennett, viz: 1st, Contrac- 
tion of the capillaries, and diminished velocity through them 
of the flow of blood; 2dhj, Dilatation of the capillaries, and 
diminished velocity of the blood's current; odhj, Oscillation 
of the column of blood, and encroachment on the lymph 
spaces; Athlij, Complete stagnation of the blood, the red cor- 
puscles crowded together in an amorphous mass, and brought 
into immediate contact with the vascular walls. 

During the latter stage of this process, or at its termination, 
three circumstances might take place: 1st, Efll'usion of serum; 
2dbj, Exudation of blood plasma; and, 3dly, Extravasation 
of blood by rupture of the vessel. The object of the com- 
munication was to describe the changes which followed exu- 
dation of the liquor sanguinis. 

The blood plasma on being exuded from the blood-vessels, 
might remain fluid for some time, and would then be neces- 
sarily reabsorbed. Vogel and Vogt refer to cases where on 
cutting across small cavities in the brain, the fluid they con- 
tained immediately coagulated. More frequently, however, 
instead of remaining fluid, the blood plasma coagulates. 
When this has once occurred, it undergoes changes, which 
vary in different cases, before it can be reabsorbed or re- 
moved from the system. The material exuded constitutes a 
blastema for the formation of nucleated cells, which gene- 



378 



Abnormal Nutrition. 



rally, though not always, vary in character according to the 
nature of the tissue in which the exudation takes place. 

In parenchymatous organs, the liquor sanguinis usually 
coagulates in the form of granules, which may be seen coat- 
ing the vessels, and filling up all the space between the ulti- 
mate tissue of the organ. By this process, the organ affected 
is rendered perfectly dense or hepatized. After a time, or 
during the exudation, nucleated cells, {exudation corpuscles), 
are formed, which vary in size from 1-lOOth to l-25th of a 
millimetre in diameter. They become filled with granules 
from l-500th to l-700th of a millimetre in diameter. The cell 
wall then bursts, and the granules escape. By means of this 
process, and the development of the exuded mass more or 
less into cells, it is broken up, and rendered fluid. Thus the 
morbid state in organs, named softening, is produced. 

The exudation corpuscle may be distinguished by its un- 
dergoing no change on the addition of acetic acid. Ether 
and caustic potash entirely dissolve them; liquor ammonia 
renders them soft and easily broken down. 

On the surface of serous membranes, the exudation gene- 
rally passes into cells and very minute fibres. These cells 
{plastic corpuscles) are transparent from 1-lUOth to l-75th of 
a millimetie in diameter, formed of a delicate wall, contain- 
ing granules 1-lOOOth to l-600th of a millimetre in diameter, 
varying in number from 3 to 12. They are not perfectly 
round, but somewhat irregular in form. The mode of forma- 
tion of the minute fibres is unknown. Gulliver has pointed 
out that they are not the result of cellular development. 

The plastic corpuscle may be distinguished by its wall con- 
tracting, and the edge becoming thicker on the addition of 
acetic acid. The shape is also rendered more irregular; it is 
dissolved in ether and caustic potash, and not aflfected by 
water. 

In the skin, loose cellular tissue, &c., the exudation com- 
monly passes into cells, usually from 1-lOOth to l-i20th of a 
millimetre in diameter, perfectly round, with a defined edge, 
containing several granules, and sometimes a round nucleus. 
These cells {pus corpuscles) swim in a fluid, roll freely on 
each other, are of a yellow-greenish color, and constitute the 
organized part of the fluid universally known as pus. They 
are not formed from the exudation corpuscle, or epithelial 
cells, as has been supposed, but arise primarily from the exu- 
ded blood plasma. 

The pus corpuscle may be distinguished by its swelling out 



Abnormal Nutrition. 



379 



and becoming more transparent on the addition of water; by 
the ceil wall being dissolved, or nearly so, in acetic acid, 
whilst the nucleus is rendered more distinct in the form of 
two or three granules, generally from l-300th to l-400th of a 
millimetre in diameter. They are dissolved in ether and con- 
centrated alkalies. 

The exudation, plastic, and pus corpuscles, although most 
commonly formed in the situations referred to, are not exclu- 
sively so. The pus corpuscle may sometimes be formed in 
parenchymatous tissues, and exudation corpuscles in cellular 
tissues. Sometimes they may be more or less mixed together. 
Thus the plastic and exudation corpuscles are commonly 
formed in the lung; and exudation corpuscles may frequently 
be found swimming among those of pus. 

The exudation may also pass into organization of tissue, 
apparently by the same process as takes place in a state of 
health. Should it exist in small quantities, and further exu- 
dation be checked by bringing the divided parts into apposi- 
tion, reorganization of tissue occurs rapidly, and union by the 
first intention is established. On the other hand, when this 
process takes place slowly, a state called hypertrophy is pro- 
duced. 

When loss of substance is occasioned, the exudation passes 
partly into organization of tissue, and partly into pus corpus- 
cles, by means of which a granulating surface is produced. 
A fungous granulation examined under the microscope, exhib- 
its all the stages of development presented by cells, passing 
into fibres, as figured by Schwann. Externally these are cov- 
ered with pus corpuscles. As the former increase the latter 
diminish, until at length a normal tissue is reproduced, or a 
dense fibrous mass denominated cicatrix. 

Lastly, the exudation may be transformed into nucleated 
cells of different shapes, round, oblong, caudate, stellate, more 
or less squaie, &c. &c., either mixed or unmixed with fibres, 
constituting the dillerent kinds of morbid growths, as indicat- 
ed by Miiller. 

Thus in the same manner as in a state of health, cells ori- 
ginating in the effused liquor sanguinis, may undergo differ- 
ent kinds of development, as into fibre, muscle, nerve, &c., 
constituting normal nutrition; so in a morbid state cells ori- 
ginate in the exuded liquor sanguinis, which are transformed 
into exudation, plastic, pus cells, tumours, &c., constitutihg 
abnormal nutrition. 

Dr. Bennett agreed with Andral and Magendie in consider- 
ing that the term inflammation was inapplicable to the expla- 



380 Tubercular Deposits in the Bronchial Glands. 



nation of the phenomena he had described. He pointed out 
how the cardinal symptoms of intlammalion, pain, licat, red- 
ness, and swelUnij, were partly dej)cn(iont on the exudation, 
and partly on the congestion wliich i>recedcd it. Ho had 
even seen some cases of encephalitis, where the central parts 
of the brain were softened, and contained numerous exuda- 
tion corpuscles, although during life no pain or heat, and after 
death, no rednciis or swelling had been observed. 

Indammation, therefore, was only a part of one great mor- 
bid action occurring in the frame, which might be denomina- 
ted abnormal nutrition, and more especially that species of 
it dependent on increased exudation of liquor sanguinis. 

Numerous authors had referred inflammation to increased 
nutrition or secretion. Dr. Alison more especially seemed 
to consider this essential to the inflammatory process, (Lib. 
of Med., Art. Injlammalion). Before the doctrine of cyto- 
genesis was established, however, nutrition of parts was inva- 
riably connected with vascularity, and pus was considered an 
unorganized fluid. At present we must regard pus, lymph, 
softening from exudation, &.C., as being highly organized, and 
resulting from an active process of nutrition. Hitherto in- 
creased nutrition, as connected with inflammation, has been 
mere hypothesis; Dr. B. stated, that it was the object of his 
communication to demo asl rale its correctness. — Lond. and 
Eden. Month. Journ. Med. Sc., Dec. 1842. — Jl merican Journ. 
Med. Sci. 



Tubercular Dejwsits in the Bronchial Glands. — Drs. Rilliet 
and Bautiiez, from their extensive researches into this inter- 
esting subject, find, that, by compressing the vena cava supe- 
rior, tubercular enlargement of rlie bronchial glands may be 
tbllowed by — 1. CEdema of the face; 2. Dilatation of the 
veins of the neck; 3. Livor, in a greater or less degree, of the 
countenance; 4. Hemorrhage into the arachnoidal cavity. 

By compressing the pulmonary vessels they occasion — 1. 
Hicmoptysis; 2. (Edema of the lungs. 

When they press upon the pneumogastric nerves, they 
cause — 1. Alterations in the pitch and quality of the voice, 
and cough; "2. Violent fits of coughing, resembling those of 
hooping-cough; 3. Aslhmatical attacks. 

The action of enlarged and tubercular bronchial glands on 
the lungs and bronchi is very remarkable. By compressing 
the air-passages, they produce— 1. Sonorous rales of great 



Pulmonary Consumption in Man and Animals. 3SI 



intensity, very persistent, and of vvhicFi the quality is some- 
times very peculiar; 2. They impede the access of the air, 
whence follows obscurity in the respiratory murmur, though 
this sometimes depends on the oiderna of the lung, which is 
consequent on the pressure upon its returning blood-vessels. 
Sometimes they serve as conductors of sonorous vibrations, 
from which the following effects ensue: — 1. Alterations in the 
character of the respiratory murmur, the lungs themselves be- 
ing perfectly healthy, such as prolonged expiration, bronchial 
respiration, and all the sounds which, in the normal state, 
must take place in the bronchi, but which do not reach the 
ear; 2. Great extension of the stethoscopic indications of any 
particular lesion, as from the one side of the chest to the 
other. 

The observations, of which the above summary is given, 
were made upon children. — Lond. and Edin. Med. Journ. 
Med. Sci., Feb. 1843, from Archiv. Gen. dt Med., December, 
1842. 



Pulmonary Consumption in Man and Animals. — Rayee 
read a long memoir on this subject to the French Academy 
of Sciences, on the 25th July last. The following are his 
conclusions: — 

1st. Of all chronic diseases, pulmonary consnmption is the 
most common in man and animals. 

2d. In man and other mammalia, the tuberculous matter 
can always be easily distinguished from recent pus, which is 
loaded with seed globules. In birds, the characters of tuber- 
culous matter are less marked; foreign bodies introduced into 
the lungs and flesh, do not produce an opaque white hurnor, 
full of seed globules, but a dry yellowish matter, without glo- 
bules, whose physical characters approach those of tubercles 
in the mammalia. In reptiles, fishes, and insects, the char- 
acters of tubercle are still less distinct. 

3d. Pus, in the mammalia, and chiefly in the horse, if it 
remains long in any organ, undergoes successive transforma- 
tions, so that at last it resembles tuberculous matter. 

4lh. Pulmonary tubercles in man and in the qaadramana 
have generally a gray color; in the pommelitre of the cow 
the tuberculous matter is yellowish. 

bth. In man and animals the softening of the tuberculous 
matter in the centre cannot be attributed to inflammation, as 
no pus globules are ever seen; the softening, however, on the 



382 Pulmonary Consumption in Man and Animals. 



circumference is much assisted by the inflammation of the 
contiguous tissues, and it is almost always mixed with pus 
globules. 

Uh. The yellow matter which is found in the cysts of hyda- 
tids in the ruminantia after the destruction or spontaneous 
rupture of the cysts, has some analogy with tubercular mat- 
ter, (poiitmelitre;) but the cysts of this yellow matter almost 
always contain the debris of the hydatid pouch, and some- 
times a certain quantity of pus. 

7tk. The earthy or calcareous concretions (principally com- 
posed of carbonate and phosphate of lime) which are met 
with in the lungs of man, and other animals, ought not to be 
considered, as they are even to this day, as being almost 
always a modification of tubercle. They are frequently in 
man, and very often in the horse, the residue of a small depot 
of pus 

3th. Granulations depending on worms and on glanders 
form in the lungs of several animals, which ought to be dis- 
tinguished from tuberculous granulations. 

9lh. Among the quadrumana, and some birds brought from 
warm climates, consumption sliows itself in its greatest de- 
gree, and almost to the exclusion of other chronic diseases. 
It is equally often produced in other animals coming from the 
north, as the rein-deer, by a change of climate and food. 

10//i. Consumption, which is rare among tlic domestic her- 
bivorous (solipedes) animals, is still rarer among the carniv- 
orous. However, notwithstanding the preservative influence 
of a strong constitution, and an animal diet, several of the 
carnivora, as the domestic cat, and especially the lion, tiger, 
and jaguar brought to our country, have been seized with 
phthisis. This rarity of consumption is also seen in birds 
which are rapacious. 

lllh. By a kind of contradiction, the domestic dog among 
the carnivora, and the hare among the herbivora, are less sub- 
ject to tubercles than to cancer, a disease which Camper 
thought never attacked the lower animals. 

12lh. Among the ruminantia, and especially in the class 
boves, consumption is often associated with vesicular worms, 
and particularly with the echinococcus; but, contrary to the 
opinion several times given, there is no transformation or suc- 
cession between these hydatids and tubercles. 

13//t. Fatty liver is the common accompaniment of con- 
sumption in man, and general obesity in birds. 

I4lh. The alterations of bone which are observed in simiac 
affected witli this disease, and more particularly in those from 



Pulmonary Consumption in Man and Animals. 3S3 



New Holland, appear analogous to the deformities, swelling, 
and spongy softening of the bones seen in phthisical and 
scrofulous children. Similar alterations of bone take place 
among the carnivora brought to this country from a warmer 
climate. 

\bth. If the frequency of pneumonia, and tlie rarity of con- 
sumption in the domestic dog, would appear to do away with 
any connection between these diseases, the same thing can- 
not be said to occur in the calf, cow, or female ass, as in 
these the deposit of tuberculous matter almost always coin- 
cides with a chronic and increasing pneumonia. 

16^/t. Consumption is hereditary, but it is almost never 
congenital, even in the rudimentary state. 

11 th. Among people affected with phthisis, the semen con- 
tained in the seminal vesicles contains few or no spermatic 
animalcules. 

IQlh. Ulcers in the larynx, trachea, and bronchi, do not in- 
dicate the same thing in man and animals. In the former, 
they are almost always owing to consumption, and sometimes 
to syphilis; among the quadrumana to general tubercular dia- 
thesis, and among quadrupeds almost always to glanders. 

l^lh. In pneumo-tliorax, mouldy vegetations may form on 
the altered pleura of a phthisical patient, as sometimes takes 
place in the air-sacs of birds affected with consumption, or 
other diseases of the respiratory organs. In this case, as in 
all those which have been observed among the vertebrata, the 
development of these parasites is a secondary phenomenon. 

Rayer classes the causes of consumption under four heads: 
A domestic state and captivity for the inferior animals, and 
misery and fatigue for man; and he concludes that science, 
which is altogether powerless in curing the disease, ought not 
to be so in preventing it. — Land, and Edin. Monthly Journ. 
Med. Sci., Dec. 1842. 

In opposition to the seventh conclusion of R., Prus as- 
serts that for ten years he had been endeavoring to ascertain, 
at the Bicetrc and the Salpetriere, the curability of tubercles, 
that he has been led more and more to believe that the ear- 
thy concretions, which are almost always at the summit of 
the lung, are only modified tubercles; that they are generally, 
accompanied by traces of cicatrization; that sometimes ol^ 
cavities, lined with a new mucous membrane, co exist along 
with them; and, lastly, that it is easy to find, even in the 
same lung, tubercles in different degrees of progress, which 
present all the phases of this secretion, from its origin to its 
earthy state, and frequently the same cyst contains both tn- 



384 



Abscess of the Brain. 



bercle and earthy matter. Such are the reasons which make 
him dissent from Rayer's theory, that the earthy concretions 
are the result of a depot of purulent matter in the substance 
of the lung, and not a modification of tubercle. — Ibid, Feb- 
ruary, 1843. — Amer., Journ. Med. Sci. 



Existence of Lijmphntics in pseudo-membranes. — Mr. Ham- 
ilton was shown by Professor Vanderkelk of Utrecht, some 
preparations showing the existence of lymphatics in new and 
abnormal parts, such as the eflTusions and adventitious mem- 
branes which inflammation often leaves between the separate 
layers of serous membranes, and vvliere beyond dispute, they 
must be newly-formed lymphatics in parts themselves new. 
"The first preparation," says Mr. H., "placed in my hand 
was of this nature. The pleura, on its sacral aspect, had 
been inflamed, had thrown out coagulable lymph, which, by 
a considerable bridle, connected it with a part of the dia- 
phragm. The surface of this connection was not less than 
an inch or two in extent, and the bridle varied from a quarter 
of an inch to an inch in length. The lymphatics of these 
parts having been injected with quicksilver, the vessels of this 
system belonging to the lungs and pleura were very conspicu- 
ous; not less so those of the diaphragm; and thirdly, not less 
apparent than either, were distinct beaded lymphatics running 
along the effused membranes connecting the two normal tis- 
sues. As in this portion of the pleura, so it was equally con- 
spicuous in another preparation — a case of lympli cfiused be- 
tween the pleura costalis and pulmonalis, the bridle crossing 
like a regular bridge, and in this evidently adventitious mem- 
branous bridge were the lymphatics coursing their way as 
conspicuously as in the other parts." — Lond. Med. Gaz., Jan. 
6, 1843, from Amer. Journ. Med. Sci. 



Abscess of the Brain. — In the Archives Generales de 
Medecine, a case of abscess of the right lobe of the brain is 
published, involving some interesting and important facts. A 
girl, a servant at a public-house, in a struggle with some drunk- 
ards, received a blow from a bottle on the lateral and upper 
part of the forehead, which caused a large and very contused 
wound exposing the bone. She was admitted into the hos- 
pital on the 9lh of December, 1841, under the care of Blan- 



Treatment of Chancres. 



385 



din, and on the 13th of January, after the separation of sev- 
eral sequestra, the wound had cicatrised. The cure, how- 
ever, was only apparent; a local pain remained, which in- 
creased in severity, causing the patient to scream loudly and 
prevented her moving her head. Vomiting and insomnia fol- 
lowed, but the intellect remained clear, and also all the other 
faculties. The pulse continued regular, but the patient grad- 
ually getting worse, and her general health evidently suffering 
much, Blandin, en desespoir de cause, proceeded to trephine, 
thinking the irritation might be caused by a sequestrum or a 
purulent effusion. A piece of the cranium about an inch in 
diameter was accordingly removed, but no fracture was dis- 
covered; the parts beneath, however, presented an equivocal 
feeling of elasticity to the finger. Under these circumstan- 
ces, Blandin determined to wait, in the hope that the abscess, 
if there was one, would open spontaneously, but after the 
lapse of some time, no such result ensuing, an exploratory 
puncture was made with care, but without any advantage. 
For a time, after these operations, the poor girl seemed to be 
relieved, but the pain soon became more severe, and emacia- 
tion and prostration, followed by a severe attack of erysipelas, 
ushered in death. The opening made in the cranium by the 
trephine had not closed, and the dura mater was intact. " On 
passing in the finger after death, the same elastic feeling was 
perceived as during life, and on examination, it was found to 
correspond to a large circumscribed encysted abscess in Uie 
right lobe, separated from the dura mater by a thick layer of 
cerebral substance. It is clear that if Blandin had incised 
this layer, the abscess would have been discharged, and the 
patient had a chance for life. 

Arax, the reporter of the case, in his remarks upon it, 
draws attention to the great neglect with which the trephine 
is now treated, and although far from an advocate for its gen- 
eral use, he equally condemns its total abandonment; he also 
thinks that in serious cases, such as that under notice, the 
surgeon not deriving benefit from the treatment, should no; 
hesitate to plunge a narrow bladcd bistoury into tlie brain 
itself, and to some depth if required. — Prov. Med. Joitrn., 
Dec. 17, 1842. — Amer. Journal. 



Local Treatment of Chancres by Sulphate of Copper and 
Cijanuret of Mercury. By Dr. Strohl. — The more rapidly 
primary syphilis is cured, the less likely are secondary symp- 



3S6 Nitrate of Silver in bed So7-es. — Indian Hemp. 



toms to appear. The first object is most easily attained by 
cauterizing. Sometimes, liowever, this method is inapplica- 
ble; for instance, when the sore is very extensive, or much 
inflamed. In such cases, the author employs the sulphate of 
copper. The sores are dressed five or six times a day with 
charpie, which has been soaked in a solution of about a grain 
and a half of sulphate of copper to an ounce of water. Sim- 
ple chancres, when thus treated, usually heal within twelve 
days. Dr. Strohl assures us, that he cures complicated chan- 
cres in an equally short time with an ointment composed of 
two grains of cyanuret of mercury to an ounce of axunge. 
This ointment is spread upon a piece of linen corresponding 
to the size of the sore. This dressing is apt to be painful at 
first; and it must occasionally be taken olf, after it has been 
on for an hour or two, and the remedy must be applied in a 
weaker form. The pain is said to be most violent in half an 
hour or an hour, and frequently ceases entirely in two or three 
hours. When the chancre is extensive and painful, after the 
ointment has been on from four to ten hours, according to the 
sensibility of tlie patient, it is dressed with mercurial oint- 
ment, or opium cerate. 

If the edges of the chancre have flattened, if the centre is 
cleaner, the pain less, and the suppuration healthy (which 
may occur after the first application of the cyanuret of mer- 
cury, but, at any rate, not later than the fourth), the treat- 
ment with the sulphate of copper is finished. — Lond. Med. 
Gaz,, Nov, 1842, from Oesterr. Med. Wochenschrift. 



Nilratc of Silver in bed sores. — Mr. Henry Jackson, in a 
paper read before the Sheflield Medical Society, extolled the 
eflicacy of the nitrate of silver for the cure of bed sores. He 
mentioned one case in which "all the known remedies had 
been tried without avail," and in which a solution of nitrate 
of silver ten grains to the ounce, applied by moans of a camel- 
hair brush, over every part exhibiting the slightest appearance 
of inflammation, two or three times a day, until the skin be- 
came blackened, and afterwards occasionally, answered per- 
fectly, — Prov. Med. Journ.. Dec. 31, 1842. — Amer. Jouni. 



The Indian Hemp. — Feb. 22. — Mr. I^ky this evening com- 
municated a paper on the cannabis Jndica, from which if ap- 
pears that, although the hemp is rejected from our oiiicial 



Indian Hemp. 



387 



preparations in England, it is, and has been for a long series 
of years, in constant use as a popular remedy throughout the 
East. It exhales a powerful narcotic odour, and the branches 
are gelatinous to the touch, with a resinous secretion, which 
is collected when the seed is found (as the plant is then in 
the greatest perfection), and is sold under the name of chur- 
rus, the shoots from which the resin has not been collected, 
are cut, dried, and sold as gunjah. Although hemp is no 
longer used medicinally in England, there is an old Act of 
Henry the Eighth yet in force, by which it is forbidden to be 
soaked in ponds or running streams where cattle drink. The 
older writers speak of it as a violent poison, and state that 
the water in which it has been soaked produces its effects 
almost as soon as drank. The resin of the cannabis Indica 
is in general use as an intoxicating agent from the furthermost 
confines of India to Algiers. If this resin be swallowed, 
almost invariably the inebriation is of the most cheerful kind, 
causing the person to sing and dance, to eat food with great 
relish, and to seek aphrodisiac enjoyment. The intoxication 
lasts about three hours, when sleep supervenes; it is not fol- 
lowed by nausea or sickness, nor by any symptoms, except slight 
giddiness, worth recording. These effects are much modified in 
this country, and nuich less marked, possibly from the length 
of the voyage rendering the article deteriorated in value. The 
subsequent effects are depression of spirits and relaxation of 
the muscles in a marked degree; the Iree perspiration on the 
skin, and the increase of appetite, have made some old rheu- 
matic persons speak of it as Ihe elasticity of youth. 

Mr. Ley draws a comparison between the effects produced 
by opium and those caused by the cannabis Indica, the result 
of which induces him to give the preference to the latter, its 
influence being excited more kindly and more gratefully on 
the system. It has proved of service in cholera and rheum<i- 
tism, but it is in spasmodic and convulsive diseases that it is 
most eminently useful. In tetanus it has been the means of 
cure in the majority of cases, both in men and horses, and it 
has much relieved the horrors of hydrophobia, although not 
averted the fatal termination. It is useful, also, in chorea, 
spasmodic asthma, and delirium tremens, and generally 
wherever opium is indicated. Mr. Ley considers from this 
that it will prove a direct antidote, the first of its class, to 
strychnia, one of the most violent poisons nature affords. 

Medico-Bolanical Socidy. — Lond. Lanccl. 



38S 



Cure of Glanders in Man, 



Cure of Glanders in Man. — A wagoner, nineteen years 
of age, entered the Hopital de la Charite, in Paris, on the 
I8th of October, 1831. He complained of having felt ill for 
the week preceding, without being able to specify any partic- 
ular seat of disease. Soon intense pains were felt in the 
ankle and knee-joints, and the muscles of the leg and thigh, 
though unattended with swelling or redness. His pulse be- 
came quick, thirst intense; headach and prostration. On the 
25th of October pustules, filled with a purulent matter ap- 
peared on the instep and upper surface of the three smaller 
toes of the left foot. These pustules broke, and cicatrisation 
was completed in a few days; but a diffused swelling now 
made its appearance in the anterior part of the superior third 
of the thigh, followed by two similar tumours, one on each 
leg. Mouneret, under whose care the patient was placed, 
now suspected the nature of the disease, and ascertained that 
one of the horses kept in the stuljle where the patient had 
been sleeping actually had the glanders. For the eight 
months ensuing tumours of a similar kind to the foregoing 
were successively and incessantly appearing on all parts of 
the upper and lower extremities, though they continued one 
after another to disperse, and nothing in the general condi- 
tion of the patient, except liis emaciation, gave cause for 
alarm; yet one curious collateral circumstance is stated. Early 
in December, 1841, a horse being inoculated with the matter 
from one of the abscesses, died in the course of five days, 
without, however, presenting during life any of the ordinary 
symptoms, or after death any of the usual morbid appearan- 
ces belonging to the disease. 

The treatment of the patient was the same nearly through- 
out, consisting chiefly ot' decoction and extract of cinchona 
in large doses, with wine. 

On the 5th of July, 1842, iodine with iodide of potassium 
was administered. This was followed by an attack of erysipe- 
las in the left arm, and the iodine was suspended, to be re- 
sumed on the 17th. No new tumours had appeared during 
the previous two months; the cicatrisation of those still exist- 
ing was soon afterwards completed, and the patient was dis- 
charged perfectly cured on the 31st of July. 

Andral, and other able pathologists who saw this case, 
were unanimous in pronouncing it a true instance ot glan- 
ders. The journal from which we have extracted the above 
relation says — "The case is unique. In all the instances of 
glanders in the human subject reported hitherto the disease 
has proved fatal." — Gazette ides Hopitaux. — Lond. Lancet. 



Amount of Respiration relatively to Sex and Age. 389 



Relative value of Quinine in large doses, as a. remedy in 
Typhus. — The successful results of the practice of Sig. Bro- 
qua have been already noticed in the Lancet. But a com- 
mission appointed to examine into the correctness of a mem- 
oir addressed by Broqiia to the Frencli Academy of Medi- 
cine, reports that some of the cases cited in the n)emoir are 
not proved to have been of a veritably typhoid character, and 
in others no proof is adduced of the quinine administered 
having been the means of cure. The report of the commis- 
sion (if not belied by the journal which informs us of its pre- 
sentation) sarcastically enough remarks, that "one interesting 
fact confirmed by Sig. Broqua's memoir is the harmlessness 
(I'innocuite presque constante) of the sulphate of quinine in 
large doses;" and it recommends that the memoir should be 
honorably shelved! In tlie discussion that followed its read- 
ing, Piorry stated, that in typhus fever, with engorgement of 
the spleen, he had seen quinine prove serviceable, which had 
not been the case when the fever was unaccompanied with 
splenic lesion. Martin Solon, who had employed the remedy 
under the personal inspection of Sig. Broqua at the Hopital 
Beaujon, admitted that in cases in which the fever assumed a 
remittant type quinine was useful, but that remittent typhus 
was rare — at least at Paris. "Of five severe cases ol typhus 
fever, in which quinine had been given, death had resulted in 
three instances; and in the two others, recovery had only 
taken place after a considerable lapse of time, and without 
any evidence to show that the sulphate of quinine had been 
the means of hastening it. In the post-mortem examinations 
of the subjects who had died (says Martin Solon), I failed to 
detect any peculiar alteration that I could fairly attribute to 
the large doses of the sulphate; it had passed in a manner im- 
perceptibly through the stomach and intestines. A symptom 
I observed in those who recovered from the disease was a re- 
markable depression of the circulation. In short, I consider 
the advantage attributed to the sulphate to be more than 
doubtful." Much doubt was afterwards expressed by several 
members of the academy as to the innocuity of large doses 
of quinia or its sulphate; but finalh' the terms of the report 
were adopted, and tlie memoir was shelved by a majority of 
voices. — Gaz. des Hop. — Lond. Lancet. 



Amount of Respiration relatively to Sex and Age. — Bour- 
GERY, in a memoir read before the French Academy of Sci- 



390 Quinine in Intermittent and Remittent Fevers. 

ences, asserts that, cceleris paribus, respiration is vigorous in 
proportion as the individual is younger and thinner. No 
condition is so productive of energetic respiration as youth. 
The respiration in a man of a given age is double the amount 
of that of a woman of the same age. At thirty years of age, 
the period of plenitude of the respiratory powers in both 
sexs, a man usually respires {respiration forcee) from half a 
gallon to a gallon ('2.5 to 4.3 litres) of air (per minute); and a 
woman, from a quart to less than half a gallon in the same 
lime. A boy of fifteen respires nearly half a gallon; and an 
old man of eighty, about three pints of air (1.35 litre). A 
strong man of thirty respires as much as two men of feeble 
constitution, boys of fifteen, or strong women; and four wo- 
men of feeble constitution, boys of seven, or old men of 
eighty-five years of age. The respiration of a strong woniiia 
is accordingly equal to half the above amount, as estimated 
by Bourgery. According to the same authority, the faculty 
of respiration becomes impaired throughout life by succes- 
sive ruptures of the air-cells, which inevitably attend all ex- 
tensive respiratory efforts and other causes. Though these 
become more frequent as age advances, they occur likewise 
in infancy, and from the mere respiratory act. All diseases 
of the lung, however slight, tend also to incapacitate that organ. 

Gaz. des Hop. — Lond. Lancet. 



Quinine in Intermittent and Remittent Fevers. By S. S. 
Ransom, M. D., of Burlington, Iowa. — After several years' 
practice in the West, where intermittent and remittent fevers 
prevail, and after watching the medicinal operation of sul- 
phate of quinine upon the system in these diseases, my for- 
mer views in regard to its operation have become entirely 
changed. Heretofore I have regarded it as a powerful tonic, 
and admissible only where there was a perfect intermission 
(which is, 1 believe, the generally received opinion). 1 have, 
within the last three or four years, given it without regard to 
the intermission, remission or exacerbation, and with deci- 
dedly better success. A remittent very soon becomes inter- 
mittent under its use. We will take, for example, a case of 
bilious remittent, which is the most common form of fever in 
this Valley. After the bowels are thoroughly evacuated with 
mercurial cathartic, commence with one grain of the s. q. 
every hour, and it is rarely necessary to continue longer than 
thirty-six hours before there is a perfect intermission. Bt lbre 



Remarkable Case of Congenital Small-pox. 391 



its use, the pulse was from 100 to 120; skin hot and dry; 
tongue dry; great thirst; violent pain in the head and back. 
After the system has been kept under its use for a few hours, 
all these violent symptoms entirely vanish, and a speedy con- 
valescence ensues. 

Now what is the medicinal operation of the sulphate qui- 
nine on the system? I know of no article in the whole ma- 
teria medica which produces the same results. It has been 
accused of producing enlargements of the spleen. I have 
frequently known it reduce tliem, and I verily believe that it 
is among our most valuable remedies in chronic enlargement 
of that organ. 

If you should consider this hasty communication of suffi- 
cient consequence, you are at liberty to give it a place in 
your valuable Journal, for the sole purpose, on my part, of 
eliciting some light — for it does appear to me that this very 
valuable article of our materia medica is but imperfectly un- 
derstood. I would propose that some more able than myself 
in the profession communicate their views, and I may at some 
future day give a detailed account of the many cases where I 
have administered the article, and the results. — Boston Med. 
and Surg. Journ. 



Remarkable Case of Congenital Small-pox. — A woman, 
twenty-four years of age, entered the Maternity Hospital in 
Paris to pass he first confinement. Labor commenced two 
days after her arrival; and after the lapse of fourteen hours 
{jours, says the original, but this is evidently an error) she 
was delivered of a female child. The face, scalp, and differ-* 
ent parts of the child's body were covered by a pustular erup- 
tion, which was soon recognized to be veritable small-pox. 
The mother retained the marks of vaccination, and stated 
that she had never had the small-pox; nor during her preg- 
nancy had she had connection with persons suffering under 
that disease, nor even heard of its prevalence in her neigbor- 
hood. Only, about eight or ten days before, she had gone to 
see a patient at La Pitie, near whom lay another patient in 
the smali-pox. She had paid no attention to this circum- 
stance till recalled to her recollection by minute inquiries. 
No untoward effects ensued, either to mother or child, and 
both left the hospital in perfect health soon afterwards — Bul- 
letin de C Acad Royale. — Boston Med. Su7-g. Journ. 



392 



Dropsy of the Os Uteri. 



Dropsy of the Os Uteri. — Under this name Jobert describes 
tumefaction of the mouth and necit of the uterus, which most 
frequently occurs among women of a lymphatic tempera- 
ment, being, according to his observations, confined to those 
who have never borne a child, and who menstruate but feeb- 
ly. Examined by the aid of the speculum, the os uteri is 
seen to be so much swollen as almost wholly to conceal the 
orifice, and it gives on pressure a sense of fluctuation. It is 
uniformly pale and flabby, and may sometimes be ulcerated, 
but it is not in general organically diseased. On carefully 
introducing a bougie through the orifice, a quantity of trans- 
parent, llocky, light-colored fluid usually escapes from the 
cavity of the uterus; and, at the same time, the neck and 
mouth become relieved of a portion of their tumefaction. 
This event may happen consequent on a spontaneous dis- 
charge of the fluid, and always attends more or less the re- 
currence of the menstral discharge. The cause of the aflec- 
tion has been attributed to a distension and superabundant 
secretion of the glandular follicles of the neck and mouth of 
uterus. For its treatment after the evacuation of the con- 
tents of the uterus, Jobert advises free incisions to be made 
in the os uteri, in the direction from centre to circumference 
{dans le sens des commissures). The granulation of the 
wounds thus made, produces concurrently, as he says, an 
enlargement of the orifice of the uterus, which effectually 
obviates a return of the disease. — Lon. Lancet. 



THE WESTERN JOURNAL. 



Vol. VII.— No. V. 



LOUISVILLE, MAY 1, 1 84 3. 



TRAVELLING EDITORIALS. 

It is no doubt known to most of our readers, that Pensacola Bay 
is a permanent Navy station, and the only one west of Cape Flor- 
ida. Having for its object the protection of our commerce on the 
Gulf of Mexico, it is of special interest to the people of the valley 
of the Mississippi, and the little sisters — Pearl, Alabama, Escambia, 
Appalachicola, and Suwana, which enter the Gulf to the east of 
the great river. We shall not, then, apologize for making our visit 
to this station the occasion of an editorial; although it may embrace 
some things not strictly professsional, and others with which many 
of our readers are already acquainted. 

The Bay. 

What is now called Pensacola Bay, was discovered, three hundred 
and four years ago, by one of the followers of De Soto, by whom, 
however, it was not visited. It was then, by the Indians who dwelt 
on its banks, called Achusi. Its width varies from one to six or 
eight miles, and its length is about thirty. Lying in the latest terti- 
ary formation, its banks are composed of white and yellow sand. 
7 



?,94 



Travelling Editorials. 



The long leaved pine is the predominant tree of the forests which 
surround it, interrupted, here and there, by a cypress and titi {andro- 
meda) swamp. The traveller may wander far and wide, without 
meeting with a more beautiful sheet of water than that on which we 
are now looking out, from the verandah of the Naval Hospital, in 
one of whose untenanted wards we lodged last night. Our latitude 
is a little above the thirtieth degree — our elevation thirty feet over 
the Bay. 

Navy Yard. 

This depot of munitions of war and naval supplies, is situated 
on Tartar point, which projects into the north side of the Bay, 
about three miles from the open Gulf. This point is a bed of white 
sand, elevated but a few feet above the waters of the Bay. It is 
said to be an exceedingly healthy spot. Of its buildings, it is not 
our purpose to speak. Its present commandant is Com. Lavalette; 
its surgeon Dr. W. A. Spottswood. The officers of the yard are 
changed every three years. 

Forts. 

Within sight of the yard, are three forts, two at the mouth of 
the Bay, on the approximate extremities of Foster's Island and 
Santa Rosa Island, which are but dunes of white sand, rising a 
few feet above the tide. The former is called Fort McCree, the 
latter Fort Pickens. The third. Barrancas, is situated on a higher 
bank, two miles up the Bay, on its north side. A part of the 7th 
Regiment of Infantry under the command of Lieut. Col. Whistler, 
and having Dr. Moore as surgeon, is stationed at these forts. Their 
object is the protection of the Navy Yard, and of vessels undergoing 
repair. 

Hospital. 

The site of this edifice, is between the Navy Yard and Fort Bar- ^ 
rancas. The buildings stand on a second bank or higher terrace, 
twenty four feet above the level of the Bay, and are almost con- 
cealed by live-oaks, pines, and other evergreens; clumps and tufts 
of which partially obscure the white sand of the plain below. At 
the level of this plain, in front of the Hospital, several copious 
springs of soft water burst out, which form basins and then flow off 
t9 the Bay in perpetual currents. In the rear, and on each flank 
of the Hospital, is a plain of yellow sand, over-shadowed with 



Travelling Editorials. 



shrubs and trees of perpetual verdure; and are already, maugi'e a 
most inclement and tardy spring, in some degree enamelled with 
flowers. 

The Hospital buildings consist of two principal edifices, connec- 
ted at their ends by a corridor; of a smaller one in the rear; and 
of houses for the surgeon and assistant surgeon, in a line with the 
central structures. Each of these is a parallelogram, surrounded 
by a broad and high verandah or porch, with an elevated basement. • 
The wards for seamen consist of transverse sections, each sufficient 
to receive from eight to ten patients; and are admirably ventilated 
by means of opposite windows. The edifice appropriated to sick 
officers and midshipmen, has an entry through its centre, with small 
rooms on each side, which cannot be as well ventilated as the sea- 
men's wards. This entry is too narrow, which re.sults from the inor- 
dinate width of the porticos. In fact, the parallelograms might 
have been made several feet wider, without approaching too near 
the surrounding colonnades; whereby their capacity would have been 
much increased at a very small expense. At present there are bul 
nine patients in the establishment. It can accommodate 120, and 
has been filled to overflowing; Avhich is likely to be the case when- 
ever ships of war arrive infected with yellow fever. Indeed, expe- 
rience has shown that this is little else than a Yellow Fever Hospi- 
tal. When the disease of a seaman assumes an exceedingly chro. 
nic form, and he is not very ill, or when he has become permanent- 
ly infirm, he is sent round to the Naval Asylum near Philadelphia. 
The term of service at the hospital is three years. The present 
surgeon is the amiable and intelligent Doctor Isaac Hulse, who was 
present at the founding of the hospital in 1824, and, from requiring, 
through consfitutional infirmity, a warm climate, has been sent here 
oftener than all the other surgeons of the Navy. At present he has 
no assistant. Like the other surgeons of the Navy he is allowed to 
engage in private practice, and is often called to Pensacola, eight 
miles up the Bay, where he is greatly esteemed for his skill and 
urbanity. 

Navy Surgeons. 
As many of our young readers may aspire to places iri the Navy, 
we proceed to say something for their benefit. At present there are 
69 surgeons, 60 assistants, and 9 passed assistants. The last are 
those who stand ready for promotion. To obtain admission into the 



396 



Travelling Editorials. 



Navy, the applicant must first be a graduate, and then undergo a 
successful examination by a board of surgeons. It often happens 
that the candidate is rejected! If this occurred still oftener, it would 
be still better. In private life, people may choose for themselves, 
and so great is the popular propensity to patronize quacks and dunces, 
that if thoroughly educated graduates were always offered, they 
would perhaps be rejected. The Government, however, owes it to 
our brave and patriotic seamen and officers, exposed to all climates 
and casualties, to provide for them competent physicians and sur- 
geons. It is due, also, to the character of the nation that it should 
send out such as will bear a favorable comparison with the surgeons 
of France and England, who, in times of peace, are frequently 
brought into communication with ours. As long, then, as our med- 
ical schools (without a single exception) maintain their present de- 
graded and contemptible standards of medical attainment, their short 
sessions, and superficial teachings, it is absolutely necessary to have 
a naval board of examination — to turn back to the horn-books of 
the profession, one-third of all who apply. Not having been among 
this number, the candidate receives a certificate, when he may, if a 
vacancy exist, obtain an appointment from the Secretary of the 
Navy. But let him be aware that he is only admitted to probation. 
At the end of five years, he is subjected to a second and still se- 
verer ordeal, the great object of which is, to di.scover what his im- 
provement has been since the former — whether he has been observ, 
ing and studious, is a growing professional man, and promises to 
become eminent — if so, he is made a passed assistant, and ready in 
due time to become a surgeon. Thus, our young friends will see 
it is no child's play to get into the Navy — with whatever facility 
they may have crept into the profession, or may creep into profes- 
sorships. 

Let us now inquire into the motives and advantages of a Navy 
appointment. A naval surgeon is exposed to the dangers of all 
climates and localities, and necessarily separated, for long periods, 
from his friends and family; but, on the other hand, he has di- 
versified opportunities of improvement, pleasant companions, and ex- 
emption from the caprices and delinquencies which so often annoy 
or disappoint him in private practice, and derives importance and 
dignity from his official rank. But all this — 

"Plays round the head, but comes not to the heart." 



Travelling Editorials. 



397 



The great American question is, -which career will fetch in most 
money? As data for an answer to this momentous inquiry, we shall 
extract from the Naval Register of our friend Hulse, the following 
statement of the pay of surgeons and assistants, in 1842. 

"Assistant surgeons, waiting orders, $650 per annum — at sea 
6950. Passed Assistants, waiting, 6850— at sea §1200 — when 
stationed at a navy yard, hospital, rendezvous, or receiving ship, 
$950. Surgeons, for the first five years after being commissioned, 
$1000; for the second five years 81200; for the third $1400; for 
the fourth $1600; after the 25th year $1800. All surgeons under 
orders for duty at navy yards, hospitals, or receiving ships, to have 
an increase of one-fourth of the above amounts; if ordered to sea, 
of one-third; and if sent out as fleet surgeons, one-half. The Chief 
of the Bureau of Medicine and Surgery, at Washington, has a 
salary of $2500." From an examination of this table, we incline 
to the opinion, that if they were all in actual service, the 138 med- 
ical gentlemen of the navy, would receive as much as a correspond, 
ing number of physicians, taken indiscriminately in any part of the 
United States out of our largest cities; but it must be admitted that 
there are many in the navy, who could earn more in private prac- 
tice. 

Naxy Ration. 

Having got out of port and fairly under weigh, we shall not cast 
anchor till we have sailed a little further. We suppose that most 
of our backwoods' readers have not had an opportunity of knowing 
on what our seamen subsist, and we will, therefore, proceed to tell 
them. 

The daily allowance of each person is — "One pound of salted 
pork, with half a pound of peas or beans; or one pound of salted 
beef, with half a pound of flour, and a quarter of a pound of rai- 
sins, dried apples, or other dried fruits; or one pound of salted beef 
with half a pound of rice, two ounces of butter, and two ounces 
of cheese, together with fourteen ounces of biscuit, one-quarter of 
an ounce of tea, or one ounce of coffee, or one ounce of cocoa; 
two ounces of sugar and one gill of spirits; and a weekly allow- 
ance of half a pound of pickles or cranberries, half a pint of mo- 
lasses, and half a pint of vinegar." 



398 



Travelling Editorials. 



"Fresh meat may be substituted for salt beef or pork, and vegeta- 
bles or saur kraut, for other articles usually issued with the salted 
meats; allowing one and a quarter pounds of fresh meat for one 
pound of salted beef or pork,' and regulating the quantity of vegeta- 
bles or saur kraut, so as to equal the value of those articles for which 
they may be substituted." 

"Should it be necessary to vary the above daily allowance, it 
shall be lawful to substitute one pound of soft bread, or one pound 
of flour, or half a pound of rice, for fourteen ounces of biscuit: 
half a pint of wine for a gill of spirits; half a pound of rice for 
half a pint of peas or beans; half a pint of peas or beans for half 
a pound of rice," 

No officer or midshipman, nor seaman under 21 years of age, is 
allowed to draw the spirit part of the ration; and any one may com- 
mute it for money. 

It must be admitted, that we have travelled over a substantial 
bill of fare; and that our seamen are better fed than many of their 
brothers on shore. The diversity in their diet is highly commendable, 
and may be regarded as a main reason why they are so seldom affec- 
ted with scurvy. 

Waste of Hospital Liquors. 
In the office of the Hospital where we are writing, we find 
conspicuously pasted against the Avall, a circular from Dr. W. P. 
C. Barton, Chief of the Bureau of Medicine and Surgery, in which 
he sets forth, that great abuses have existed in the care and use of 
the liquors provided for the sick; that they have been considered by 
the officers as a store from which all might borrow, and that pay- 
ment was generally omitted; that they have been wasted on the well, 
or on those who did not need them; that it will hereafter be consid- 
ered a misdemeanor to lend even a glass of wine; and that he be- 
lieves the necessity of liquors in the treatment of the sick is greatly 
overrated. It was not without a feeling of mortification that we 
read an official statement, from such high authority, which presents 
our naval officers under such a discreditable aspect, and we fervent- 
ly hope the Chief of the Bureau may be successful in reforming 
the abuse he has made known to the world. 

Assault on the Temfcrayice Reform. 
The circular from which we have just quoted, concludes as follows; 



Travelling Editorials. 



399 



"Although the undersigned has not been able to perceive any- 
thing but future fatal reaction from the high handed ultra temperance 
cause so injudiciously, as he believes, expanded beyond its first de- 
t<ign, and of course belongs to no temperance society, still the ra- 
tional community is not entirely swallowed up in tiie mad vortex. 
Hence the moral aspect of the subject, in unison as it is with the 
popular feeling of the judicious temperance advocates of the pres- 
ent world, does not take any thing from the merits of a necessary 
reform." 

Now we cannot but deeply regret that the Chief of the Bureau 
at Washington, should have so far stepped out of the path of offi- 
cial duty, as to put forth this denunciation. 

What is it, we would asiv, that led to the causes he has so vividly 
depicted, but an overweening love of drink, prompting to an unscru- 
pulous seizure even of all provided for the sick? And what so like- 
ly to correct the evil, as to render drinking unfashionable and odi- 
ous? Why has the government abolished the army ration of spirits, 
and reduced that of the navy one-half, if drinking is necessary? If 
not necessary for soldiers, why is it necessary for people in private 
life? If soldiers are not allowed alcoholic drinks, nor suttlers al- 
lowed to sell them, the army, in theory, is a total abstinence tem- 
perance society; but according to Dr. Barton, this is fanatical, and 
if so, the spirit ration ought to be restored. Does he not know that 
total abstinence is the best method of moderating the desire for 
drink; and that the "gill a day" for the navy is a means of keep- 
ing alive the propensity? He tells us, that the "rational commu- 
nity is not entirely swallowed up in the mad vortex." This is 
true. There are a few rational friends of temperance who have not 
been drawn into it, but the number is very small. The "mad vor- 
tex" has spread itself over the wliolo country; and is not likely to 
contract, notwithstanding the Doctor sees nothing ahead but "future 
fatal reaction." He deprecates the "high handed" proceedings of 
the friends of temperance! But what are they? Is it a "high hand 
ed" proceeding, for a man to resolve and declare that he will not 
again lift the intoxicating bowl as high as his mouth? Is it "high 
handed" for a man to decline drink, when it is offered to him? Is 
it "high handed" to neglect to ask others to drink? Is it "high 
handed" to persuade our officers and seamen not to rob the sick of 
the wine provided for their relief? Is it "high handed" for a phy- 



400 



Travelling Editorials, 



sician to tell the people, of whom he is the medical adviser, that 
they would have better health if they did not drink at all? Is it 
"high handed" for us to ask the Doctor, whether every seaman and 
officer of the navy would not have firmer health, greater strength 
and activity, a milder temper, and a more willing heart, if he should 
never again taste a beverage more stimulating than tea and coffee? 
Is it "high handed" for benevolent men to address the intemperate, 
and implore them not to lay waste their habitations and beggar their 
wives and children? If it be, then the friends of the temperance re- 
form are, indeed, "high handed;" and we trust will continue so 
forever. D. 
Navy Hospital, Pensacola Bay, 
iMarch 30th, 1843. 



THE 



WESTERN JOURNAL 

o r 

MEDICINE AND SURGERY. 



JUNE, 1 843. 



Art. I. — St. Louis Hospital Reports. No. 1. By M. L. Lin- 
ton, M. D., Professor of Obstetrics in the Medical Depart- 
ment of the University of St. Louis. 

1 propose under the above caption to detail, in as concise a 
manner as possible, some of the more interesting surgical ca- 
ses treated by Professor Brainard, of the Medical Department 
of the University of St. Louis. I proceed then directly to my 
task, and Jirst to two cases of ununited fracture of about 
twelve weeks standing, treated by the starch bandage, or vn- 
movtahle apparatus. 

One was a fracture of the humerus just below the inser- 
tion of the pectoralis major. It had been treated by the ordi- 
nary method — wood splints, &c. — without success. A sim- 
ple roller was now applied to the arm; four pieces of book- 
1 



402 



Linton's St. Louis Hospital Reports. 



binder's pasteboard moistened were placed over the roller, the 
oute?' piece of pasteboard extending to the tip of the shoulder. 
On these was spread a coating of dissolved starch; and 
another roller, imbued with the same, applied over the paste- 
board. A simple roller binding the arm to the body (a thick 
compress having been placed between them) completed the 
dressing. I should remark, however, that two wooden splints 
were applied, to remain until the starch should dry, when 
they were removed — the apparatus becoming so firm as to 
deserve the epithet '■ immoveable. At the end of seven weeks 
this apparatus was removed, when consolidation of the frac- 
ture and the form of the member were found to be per- 
fect. 

The second was a case of compound fracture of the tibia, 
accompanied by extensive laceration of the soft parts. This 
had been treated by the fracturc-box until the opening and 
the injuries of the soft parts were healed. The immoveable 
apparatus was applied as before; two layers of the dry roller 
being applied next the skin. This case was not so fortunate. 
At the end of six days the member became painful; the appa- 
ratus was removed; and several ulcerations at the points of in- 
jury were observed. In his observations on these cases, the 
Professor remarked that they were well calculated to illus- 
trate the advantages and disadvantages of the immoveable 
apparatus, about which so much had been lately said. In the 
first case, the skin being intact and the bone covered by soit 
parts, no ill effects occurred, and the cure was effected with 
a facility afforded by no other method. In the second the 
bone was but slightly covered with soft parts, and neither 
these nor the newly formed cicatrices were able to resist the 
pressure of the apparatus. It is recommended to leave open- 
ings in the apparatus corresponding to the ulcers, or to the 
openings in the soft parts in compound fractures; but even 
with this precaution it is difficult sometimes to prevent the 
formation of ulcers and the discharge of thin secretions be- 
neath the bandage. Still the apparatus must not be blamed 
on account of occasional ill effects. When applied over re- 
cently formed tissues, or bony projections, these should be 



Linton's St. Louis Hospital Reports. 403 



guarded by compresses of lint or cotton. But even with all 
these precautions bad effects may follow: thus the Professor had 
seen a case in the wards of Velpeau, in which a simple was 
converted into a compound fracture of the tibia, by the pres- 
sure of the extremity of the bone against the unyielding band- 
age; and death was the result. 

Applied with caution and discrimination, it is invaluable in 
a great many cases — ununited fractures of the neck of the 
femur, or through the trochanters, are of this kind, whether 
the object be to effect a bony union or simply to allow the 
patient to walk about (on crutches) without great pain. The 
pieces of pasteboard in these cases should extend from the 
knee to the crest of the ileum, and the roller should be ap- 
plied firmly around the pelvis as well as thigh. In a case of 
this kind, in which tiie patient was kept on his back until his 
health was so much impaired as to excite apprehensions for 
his safety, the apparatus thus applied enabled him in less than 
two weeks to walk about on crutches; the forces of the sys- 
tem were gradually restored. 

In chronic cases the application of the damp' rollers is lia- 
ble to be followed by rheumatic inflammation. This should 
be guarded against by the sparing use of the starch, and by 
the use of warm applications until it is dried. 

Case III. — Vaficose veins treated by needles and ligature. 
The subject aged fifty-five years, had varicose veins of both 
legs attended by chronic ulcers. This case was of twenty-six 
years standing. The Lecturer remarked, that the propriety 
of attempting the radical cure of varicose veins iiad been 
called in question by many surgeons; it had also able advo- 
cates. This conflict of opinion had, he thought, arisen from 
the confounding of two different states of the veins. Varicose 
veins are produced by the obstruction of the venous canals 
to a partial extent, as is observed in pregnancy — varicose 
states thus induced, or by similar causes, are distinguished 
by a knotted appearance which arises from the hypertrophy 
of a portion of the circumference of the vessels; these enlarge- 
ments appear first at the valves; increasing, the valves are 



404 



Linton's St. Louis Hospital Reports. 



forced and give way, the upper ones first, the lower ones as 
the disease advances. In the case before you, said the Pro- 
fessor, if you place your finger upon these enlarged branches 
below the knee, and then give a quick stroke upon the sophena 
where it dips down to join the femoral vein, you will feel the 
shock below, showing that the valves are imperfect. Tliere 
is another class of enlarged veins, produced by the perfect 
obliteration of certain important venous trunks. The collat- 
eral veins enlarge to supply their place; these latter are hy- 
pertrophied in every sense of the term, and, when superficial, 
can be seen running in a serpentine or zigzag manner under 
the skin. He had seen an example of this vicarious enlarge- 
ment in the service of Cruveilhier, in which, from oblitera- 
tion of the ascending cava, the subcutaneous abdominal and 
thoracic veins were enormously enlarged; and another in pri- 
vate practice, in which the same result followed obliteration 
of the saphena. The difference between these kinds of cases is 
obvious: in the first, the circulation is retarded in the enlarged 
vessels; in the second, it is increased, these latter deserving 
the name of suppleant or vicarious veins. It would be bad 
practice to obliterate these; the former only call for an opera- 
tion. But would it not be better to confine our eflforts to 
palliatives? say the roller, laced stocking, and starch-bandage? 
The gravity of the disease and the great length of time re- 
quired for such means to effect any thing, prevent us from 
hoping much from them. Let us examine then the different 
modes of obliteration. We pass over the ligature, excision, 
&c., as practised by the older surgeons, and come directly to 
the two favorite methods of the present day, viz: the caustic 
and the needles with ligatures. The latter of these methods 
is principally advocated by Velpeau. He passes a needle be- 
hind the vein and embraces it with a thread, as in the twist- 
ed suture, so firmly as to occasion a sloughing of the comprised 
vein and integuments. This usually causes but little 
pain or inconvenience. In twelve hundred cases operated 
in this way by Velpeau, but one death has occurred. The 
former method, practiced by Berard at the Neckar Hospital, 



Tellkampf on Amputation of the Arm. 



405 



consists in the prodLiction of the slough by the use of the 
potassa fusa, or the potassa cum calce. In both methods the 
same result is arrived at — the vein is obliterated. Berard 
already (eighteen months since) boasts of one hundred cases 
treated in this way, without one death. But, added the Pro- 
fessor, in visiting his wards I observed numerous cases of 
troublesome abscess, clearly the result of this mode of treat- 
ment. For this and other reasons I prefer the method of 
Velpeau. The Professor then operated as already indicated, 
placing the needles under the two principal trunks of the 
enlarged veins. At present, after four weeks, the veins are 
obliterated and no ill effects have followed. 
January, 1S43. 



Art. II. — Amputation of the Right Arm at the Shoulder Joint. 
By T. A. Tellkampf, jM. D., of Cincinnati, Ohio. 

Feb. 5th, 1S42. Anthony Newhouse, aged twenty-five, and 
of healthy and vigorous constitution, a workman in Mr. W's. 
steam-brewery near this city, got entangled is the connect- 
ing cogs of the large transverse wheels of the machinery of 
the establishment, was drawn in between them, and pulled 
through to the other side, where he was soon after found. 
The bones of the right hand were almost entirely crushed; 
the muscles of the forearm were torn and lacerated, and bore 
the marks of the cogs; the arm was broken and crushed in 
its central portion, the splinters of bone projecting here and 
there— forming almost an indistinguishable mass of bone, 
muscular substance, muscles, nerves, bloodvessels, &c. The 
nerves and vessels were to some extent isolated. The upper 
and lower extremities of the humerus were both split, the 
fissure extending into the joint, as was ascertained by mo- 
tion. Besides these, the patient had received other and severe 
injuries. The skin and muscles along the right side down to 
I * 



406 Tellkampf on Amputation of the Arm. 



the pelvis (upon the edge of which the wheels had apparently 
rolled off) bore the marks of the cogs; three ribs were frac- 
tured; and there were wounds from four to eight inches long in 
the abdominal parietes, some of them penetrating to the peri- 
toneum. The patient was removed to a house adjoining the 
brewery, where on my arrival, I found him, faint from pain, 
not from hemorrhage of which there had been little. As 
there was reason to apprehend tetanus from the increasing 
sensibility of the patient, with the assistance of Dr. Emmerth, 
who was with the patient when I arrived, I prepared for 
operating on the arm immediately, amputation at the joint 
being evidently the only remedy that could be adopted. 

The patient was put in the proper position and some of his fel- 
low workmen directed to hold him. Dr. E. compressing the sub- 
clavian artery, I drew the arm a little outwards Irom the 
body, and passing the knife over the shoulder, I cut first 
downwards from the top of the shoulder on its upper and 
outer surface to about the point of insertion of the latissimus 
dorsi and teres major muscles; thence returning with it in 
the same cut to about two finger's breadth below the acrom- 
ion, I passed downwards and inwards on the arm towards the 
point of insertion above named, and to within about two fin- 
ger's breadth of it. With this nearly circular cut, the skin 
and all the muscles of the arm at the shoulder were severed 
and the socket laid bare; passing back in the wound, the sock- 
et was fully opened. Raising the arm up out of its socket 
and passing the knife over the head of the humerus, the re- 
maining portion of the ligaments and the muscles underneath 
were cut, and then nothing remained but to sever the part 
of the skin left uncut between the ends of the first named 
nearly circular incision, which I did from without. I have 
followed in this the method of Langenbeck, who first intro- 
duced and applied it in Germany, and gave the operation the 
name of extirpation of the humerus. The lime required is 
about half a minute. The wound that is left forms a perpen- 
dicular line. 

The arteries and veins being secured, after a little I dressed 



Tellkampf on Amputation of the Arm. 40T 



and bandaged the arm, using sutures secured by strips of ad- 
hesive plaster. It is not necessary to give details of the subse- 
quent treatment. The patient was placed in such a position 
as to keep the fractured ribs in apposition. Some tendency to 
cough was manifested; he complained of great pain in the 
right side of the chest and abdomen, and in the region of the 
kidneys particularly. 

The following day {Feb. 6th) the wound was a little swol- 
len, not painful; slight cough; the pains in the right side of 
the breast and abdomen increased. 

Feb. 7th. The face flushed, pulse full and soft; tongue coat- 
ed; no pains in the breast; breathing freer; no blood was 
raised with the phlegm from the cough; severe pains still in 
the right side of the abdomen, none in the left; bowels loose; 
urine brown, clear and without sediment. 

Feb. 9t/i. The wound of the arm was healed about two- 
thirds dov/n from the shoulder; moderate discharge of pus 
from the lower part of the wound. I found one of the wounds 
in the side discharging serum and pus from near the os 
sacrum, and the probe could there be introduced al)out four 
finger's breadth in the direction of tlie kidney; urine still clear 
and without sediment. Suppuration under the contused skin of 
the abdomen very copious: the most contused parts com- 
menced mortifying, to which warm aromatic poultices were 
applied from the beginning. 

Feb. I4lh. Copious discharge of scrum from the above 
named fistula: a seton applied, and after two or three days 
no serum flowed out; J opened this and several other fistu- 
lous canals with the knife. 

Feb. \6th. The patient free from pain, and the suppuration 
under the skin of the abdomen very free, but favorable. 

The first ligature of the shoulder was removed on the ISth, 
(thirteenth day from the injury). The patient improved 
gradually and equably. Upon the sloughing ofl' of the skin 
of the abdomen, I had it dressed twice daily with lint. The 
only drawback to his recovery was his endeavoring (March 
lOtli) to heal up the the suppurating surface on the abdomen 
faster than I had intended, by using of his own accord a solu- 



408 



Cases of Tardy Fecundity. 



tion of nitrate of silver I had formerly used on the other 
parts, and the favorable effect of which he had noticed. This 
checked the suppuration, brought on pains in the abdomen, 
and caused a swelling of the left leg. By reproducing the 
secretion, these symptoms passed off and the patient recov- 
ered rapidly. A generous, nourishing diet was directed for 
him, to keep up his strength whilst suppuration lasted. The 
wound of the arm was healed about the 5th of March. In 
the beginning of April, when the wounds of the abdomen 
were almost healed up, 1 applied two setons on the breast. 
The latter wound left a smooth surface, no folding of the 
skin so as to inconvenience him at all in walking or other- 
wise. He has regained his usual health. 
March, 1843. 



Art. III. — Cases of Tardy Fecundity. — Translated from a 
French manuscript* for the Western Journal of Medicine 
and Surgery. By Daniel Staiil, M. D., of Vincennes, 
Indiana. 



Fecundity of a John Moulard of Bern, died m 1710, at the age 
man 99 years of „ , , ,^ , , . r i ■ i • i 

age. of 110 years, almost sound in leehng and judg- 

ment. He had married 10 wives, the last at the 
age of 99 years, she being 18 years old. Two 
years after she had a son. — Almanack des Centen- 
aires of the year 1761, p. 67. 

ofanianatioo. A peasant died at Sinkoping, in Sweden, at the 



* I received this manuscript from a highly valued and now departed friend", 
who, while pursuing his medical studies at Paris, collected the above cases. Ex. 
changing subsequently the ministry of the body for that of the soul, I feel some 
delicacy in giving his name to the public, which moreover is the less necessary, 
as the reader, in most of the cases related, can refer to the sources whence 
hey have been derived. 



Cases of Tardy Fecundity. 



409 



age of 108 years; was married to the third 
wife at the age of 100 and had a son from that 
marriage. — Journal de Verdun, 1754, p. 103. 

Fecundity of a Antoine Nonathac, in Limausin, died in 1757, 
92 years of the age of 115 years; married three times; the 
second time at the age of 92, from which marri- 
age he left some children; and the third time at 
102 years. — Affiches de Paris, 175S, page 191; 
Gazette de France, 1758, page 139. 

of a man at Massinissa, king of Numidia, had at 86 years 
of age, a son born to him, named ]Metimnatus. — 
Valer. Maxim., book S, ch. 7. 

of a woman at Mary Volmerange died at Metz, at the age of 

•>9- 100 years, in 1742, had 24 children, the last of 

which she had at the age of 59. — Etrenne Mig- 
non de 1743. 

ofaraanatOJ. Chevalier Bulstrade died at St. Germain, in 
1711, at the age of 105; had 17 children, the 
last of which was born to him in his 9 1st year. — 
Almanack des Ccntcnaires, 1761, p. 40. 

of a woman at A woman of Carpentras, still had her catamenia 
at the age of 106 years. — Memoirs of the Acade- 
my of Sciences. 

ofamanatlOo. The Journal Encyclopedique of the year 1779, 
relates the case of a man then living at Tau, who 
at the age of 110 was very active (trcs agile). He 
married at the age of 105 a young girl, who two 
years afterwards had a child by hitn. 

ofamanat 88. In 1762, near Varlovie, at the place of Mr. Za- 
luski, Slaroste of Goujeck, there died a peasant 
at the age of 157 years. At the age of 88 (after 
having lived 58 years with his first wife) he mar- 
ried again and had 7 children. 

of a man at 82. Jean Rovin died in Hungary, in 1740, at the age 
of 172 years; his wife was 164 years old. They 
lived together in wedlock 147 years. At the 
birth of their youngest son, the father was 82, and 



410 



Cases of Tardy Fecundity. 



Fecundity ol a the mother 74 vears old. — Mercure de France, 
woman at74. j^^g^ p_ jg^. j'^^^^^i Verdun, 1740, p. 299; 

Alman. des Centenaires, 1761, p. 122. 
ol" a man at 88 Pierre Zorten, of Hungary, died in 1724, at 

years of age. 135 ^^^^^ ^orn to him at 88.— 

Journal de Verdun, 1740, p 299; Mercure, 1756, 
p. 157. 

of a man of 80. A man 80 years old had his wife pregnant with 

the 6th chM.—Hohuken Epist. 13. 
ofaiiuin atlio Two brothers cited by Buffon. 

and one at 112 
years. 

of a man at 70. This man gave no manifestations of puberty 
until be -was 50 years of age; he was married at 
70 and had 5 children, and died at the age of 120. 
Buffon, tom. 8, p. 132. 

ofamauatoo. A Spanish surgeon in the diocese of Commin- 
ges was married to his second wife at the age 
of 90 years, and became father of a very vigo- 
rous daughter (une fille tres vigoureuse). Died at 
112 yedivs.— Gazette de France, 1759, p. 60; Af- 
Jichesde Paris, 1759, p. 12. 

of a woman at A Woman of 69 years menstruated, but was 
sickly. 

of a woman at A nun menstruated at 79 years of age, 

79. * 

of a woman at Two women of more than 80 years menstrua- 

ted. Cited by Louis Courseur.— £nc. Meth. Me- 

dicin. tom. 2, p. 506. 
of a woman at Valesins has seen a woman having a child at 

61 and continue to have them to the age of 67. 
of a woman at A woman in Avignon had a son at 70 years. — 
"0- Pare, in folio, p. 623. 

of a woman at Jn the diocese of Seeze, a man of 94 years, 
married a womati of 83, and they had a son to- 
gether. The Bishop of the Diocese, who knew 
them, cited the fact to the Academy of Sciences, 
and it is reported by his historian. — Merveilles de 
la Nature, art. Fecundite. 



Cases of Tardy Fecundity. 



411 



Fecundity of a In the Journal Politique, of 1773, it is stated 

man at 9.}, and -r r o • 

a woman at 65. that the Wife of bieui Grant of Newri, aged 65 
years, was delivered of a son; and to heighten 
the marvel of this circumstance, it is stated that 
the father, Sieur Grant, was 95 years of age. 

of a woman at A woman of 60 years was delivered of two 

60. •' 

sons (twins) at Sally, in Hungary. — Exlrait des 

Annales de la Reqnibl. Francois, Journal du 27 

Vendemaire, an 7. 
60 * Tcouiard^ ^ noble Venitian lady, was delivered at the 
has given the age of 60, after a pregnancy of 15 months. (Two 
details.) jj^g^g apocryphal.) — Nouvelks Observations 

sur les naissances tardives. Paris, 1765, p. 

95. 

of a woman at Another noble Venitian lady, aged 60 years, 

60, and a man , i i i i <~r\ 

at 70. Goaiard. had a daughter by her husband, aged <0. — Mu- 
sa Epist. 29, t. 2. 

of a man at 80. Cato, at the age of 80,' impregnated the daugh- 
ter of one of his clients. 

ofamanatioo. Nicholaus, of Polavicene, had a child born to 
him at the age of 100 years. — Ibid. 

ofamanatioo. Leninius cites the fact of a man aged 100 years, 
who married at Stockholm a woman of 30, and 
had several children by her. — Ibid. p. 96. 

ofamanatioo. Platerus, Liv. 1. observes that his great father 
on his mother's side, aged more than 100 years, 
married a girl of 30, and had a daughter; and 

of a man at 77. ^j^jj^ his father, Thomas Platerus, married at 77 
years of age, and had 6 children. 
Ibid. p. 96. 

of a man at 73. Segismund Polastrc, a physician, who taught 
Phi-losophy at Padua, having had the misfortune 
to loose his 4 sons, married again at the age of 
70, and had yet 3 sons. He died at the age of 
94 years. — Recueil d'Hisloires de Siinon Goulard. 

ofawonranat The Countess of Fiasque, had, at the age of 
54, a daughter by her husband older than hQx- 
seU.—Ibid. 



412 



Fallen on Congestive Fever. 



Fecundity of a A woman who menstruated yet at 60 years of 
age, had 3 children after the age of 67 years. 
Ibid. 

of a woman of "The Countess of Chaumerai, aged 68 years, 
of 78. was delivered, on the twenty-ninth of November, 

1797, of a hardy son, at Castillon, Department 
de la Uordogne; the father is 78 years old." — 
Extracted from public paper& of that date. 



Art. .—Covgestive Fever. By M. M. Fallen, M. D. of 
St. Louis, Mo. 

Amongst the various forms of fever which prevail in the 
south-western part of the United States, there is none more 
entitled to the investigation of tlie pathologist than that which 
has been called Congestive Fever. The frequency of its ap- 
pearance, and the ravages it commits, seriously demand that 
it should be studied with a view to ascertain its true nature, 
so as to enable us to meet it promptly, energetically, and 
skilfully. The investigation of disease requires something 
more than a mere observance of symptoms; it is necessary 
to trace those symptoms to their causes, to understand the 
pathology of morbid actions, and to apply judiciously our 
therapeutical indications. 

Impressed with this view, the writer of this essay endea- 
vored, during a residence of seven years in Vicksburg, Mis- 
sissippi, to embrace the many opportunities he had of study- 
ing the nature of this formidable malady, and to ascertain 
the best method of curing it. The observations he has col- 
lected, although made in latitude 32° 30' may not be inap- 
plicable to a more northern one, as from the recorded expe- 
rience of those who have seen the disease in various parts of 
the United States, he is induced to believe that it is essenti- 
ally the same. 



Fallen on Congestive Fever. 



413 



Symptoms. — The manner of the invasion of congestive fe- 
ver varies. Some persons are taken down suddenly, without 
any premonition; others experience for a period, varying from 
one to four days, feelings of languor, lassitude, and the usu- 
al symptoms preceding other fevers; whilst in a third class, 
it will take the place of the cold stage of an intermittent, 
whether tertian, quotidian, or double tertian. 

When the disease manifests itself, there is usually great 
depression of the muscular powers. The skin is of a pale 
ashy hue; it looses its natural elasticity, and if pinched up 
with the fingers, it will retain the form so given to it, being 
unable to regain its natural position. There is an icy cold- 
ness over the whole of the extremities, but some heat about 
the thorax and epigastrium; great restlessness — the patient 
tossing himself from one side of the bed to the other; when 
the intellect is not disturbed, the eyes have a peculiar ex- 
pression of restless anxiety. There is great distress about 
the epigastric region, as if a weight were pressing on it. 
The respiration is hurried and oppressed, and the patient en- 
deavors to assume the erect position in order to breathe 
freer. The pulse is small and frequent, and often very fee- 
ble. The tongue is paler than natural, covered with a thin 
white fur, and moist. There is usually nausea — sometimes 
vomiting. The thirst is intense. The bowels are generally 
loose, and the discharges are thin and of a dirty grayish as- 
pect; if the liver be engorged, the dejections become reddish, 
and look like water in which butcher's meat has been 
washed. Such are usually the symptoms, when the enceph- 
alon does not bear the weight of the disease. But it some- 
times happens that this organ is the first to suffer. In such 
cases the patient is seized at once with profound coma — the 
eyes are fixed — the limbs are rigid, and there is a total want 
of sensibility. Needles run into the skin provoke no evi- 
dence of being felt — the strongest rubefacients make no im- 
pression; the temperature of the surface is here also very- 
unequal, the extremities being icy cold, whilst about the 
head and over the chest it is more elevated, The bowels 
2 



414 



Fallen on Congestive Fever. 



are not so liable to be loose as in other cases, but if so, the 
discharges are involuntary. The pulse is oppressed, inter- 
mittent, and sometimes almost imperceptible; respiration 
is performed with difficulty. 

Such conditions as the foregoing will continue from eight 
to thirty-six hours, and, unless reaction be established, will 
terminate in death. If reaction come on, by the force of 
the vital energies, it will usually do so from three to eight 
hours from the commencement of the attack. The reaction 
however, under such circumstances, is very imperfect. There 
is some elevation of temperature over the thoracic and ab- 
dominal regions. The extremities lose their icy coldness, 
but do not attain a natural heat. The skin is dry, or else 
covered with a profuse and exhausting perspiration — the 
pulse is fuller than it was, but still weak, compressible and 
frequent. There is, however, a great abatement of the rest- 
lessness and the functional distress generally. This feeble 
stage of reaction lasts until the next paroxysm comes on — 
usually, however, this is not so severe as the first, and such 
a state of things might throw the practitioner off his guard. 
The third paroxysm is more severe than the second, as will 
the fifth be more severe than the fourth. In this manner the 
disease is analogous to a double tertian intermittent. Cases 
are sometimes met with, however, in which the reaction is 
not only complete but very violent. This stage of reaction 
lasts from twenty-four to forty-eight hours, then to terminate 
in a collapse from which the patient never recovers by the 
unaided efforts of nature. 

Anntomical Ckaracters. — The morbid appearances found 
in persons who have died from congestive fever are various, 
but they agree in showing an abnormal accumulation of 
blood in some of the viscera. In the cavity of the head we 
sometimes find the arachnoid membrane to be injected, 
and the vessels of the brain distended and engorged with 
blood. 

In the thorax, the lungs are nearly always engorged, and 
when cut into, exhibit portions of a dark red or brown color. 



Fallen on Congestive Fever. 



415 



In the abdomen, the mucous membrane of the • stomach 
and duodenum is usually injected — presenting that dark vas- 
cularity to which the term venous congestion is applied. 
The intestines sometimes partake of the same condition — 
sometimes do not differ from their natural appearances. 

The liver is frequently gorged with blood, presenting a 
purple appearance; the density of its structure is sometimes 
increased, but more often it is softened. 

The spleen is always aflfected — there is an increase of its 
size and consistence — it is easily torn — its normal struc- 
ture is destroyed, the interior being pulpy and of a reddish 
black. 

Nature. — The nature of congestive fever can best be inves- 
tigated by an inquiry into its proximate cause. The lesions 
revealed by the scalpel are too evidently the result of the 
disease, to induce the pathologist to appeal to them to elu- 
cidate the morbid actions which produce its phenomena. 
We must clearly then study the disease itself from its incep- 
tion to its termination, through all its phases, to arrive at 
its true nature. By doing so we are led to believe that the 
proximate cause of congestive fever lies in an irritated and 
perverted condition of the nervous system. The morbific 
cause, whatever it may be, which produces the disease, ex- 
erts its influence on the nervous system, by which innerva- 
tion is no longer distributed in a healthy and regular man- 
ner. The suddenness of the attack in many cases, followed 
by profound coma, the stertorous breathing, the insensibility 
to all kinds of irritants, the diminished temperature, une- 
qual in different parts of the body, the great restlessness, 
the periodicity of the attacks in cases where reaction comes 
on, all point to the important parts which the nervous system 
sustains in the disease. The nervous fluid which it supplies 
to the different organs of the body, to enable them to per- 
form their functions, is no longer sent out in an equable and 
healthy manner; the harmony of actions in the human sys- 
tem is broken up, the heart and arteries, and capillary sys- 
tem, no longer perform their duties; the circulation of the 



416 



Fallen on Comgesiire Ffevr. 



blood becomes retaTded. congestiou of the internal orsraos 
takes place, secretions are arrested, or depraved: the capil- 
laries no longer receiving their due supply of arterial blood, 
and innervation being perverted, calorification is altered and 
partially arrested — hence the diminished and unequal tem- 
perature. 

Causes. — ^The predisposing causes of congestive fever are 
sufficiently obscure. They are unquestionably lliose which 
produce ordinary intermittent fever, but in a very concentra- 
ted state. 

CJongeslive fever usually prevails in those localities where 
intermittent fever is rife; in fact, as has been observed 
above, a disease which commences as a well marked 
case of intermittent fever, will sometimes terminate in as 
equally well marked a case of congestive fever. ^Yhenever 
tliis occurs it is in old persons, or those of an infirm consti- 
tution, or in habitual drunkards. We may well assume 
that congestive fever is nothing more than a malignant inter- 
mittent, with very little, or no power of reaction. 

The exciting causes can be frequently traced to exposiue 
to rain, when the body is heated and perspiring: more £re- 
quendy it can be traced to the direct rays of the solar heat; 
hence in the south, laborers in the fields, and mechanics 
who work in the open air, are more frequently attacked than 
others. Often, too, it follows a simple remittent and inter- 
mittent by the abuse of evacuants; a powerful cathartic, 
which, by inducing large watery stools, prostrates the vital 
powers, converts those diseases into congestive fever. But 
this is really merely changing the quantity of disease. 

Treatment. — Bloodletting has been highly recommended as 
a remedy of great value. It is supposed "to promote reac- 
tion by diminishiug the load under which the heart and other 
vital organs are laboring." A little reflection however ought 
to convince us of the impropriety of this view. The morbid 
phenomena do not depend by any means on a mere physical 
accumulation of blood in the central organs. There is a 
previous cause which has produced the retreat of the blood 



IIT 



aoeqoai circolatcon of iu Witbdmnc:- 
not prereDt tfait oiie)|iial tendencf la p '^ 
an aDimaJ be bled to death, aotopne exar 
that notvith'tandiog the anioimt of Uoori 
aeqoeooe of that rery Um, coDgesiioa ot 
ed- Ercrjr one who has been extennr^ 
practice of obstetrics, has bad an oppottac. 
loma of a inarieed determinatioa of Uo' 
wocnea who hare sofiered from profoBe . 
Clearly then, the diannatioQ of the quae 
me Amd cannot ptrrent coo^estioo. I: 
peodeat of the amoont of bbod in the ij^ii-.. W.-.i:, 
follows the toes of bUtod, it results froai a oerroiB untatian 
which it^if is prodooed from that ke; thns exhibhiog hsv 
latimately the oerroiB and drcnJatorf systems are «— wi^»rfftl, 
and bow they act and react on each other. It is not pre. 
-ended ta be denied that pJethora may iodoce a eonditkia that 
wiil prodoee congestion, bot the mamier of actioo in soeh 
cases is ohvioos. We can aow see that bloodiettio^r, if it h 
ro act in this poreiy physical manner, is meies. Bat it ia 
worse than lueies. It is peniidaos. What have been the 
results of experimenu made to test the aceora^ of Dr. 
MackiQtosh's riews of the me of the lancet in the eoid sta^ 
of an intermiiteot feter? They show that the pbn has a 
great t^adecicy to coorert tne hitermittent into a rvmitien 
or coatinoed terer— a residt always to be depvecaicd. If Mkm 
be the resuit in many caas of ampie ratermittent, what can 
we anticipate in the maBgOTnt form, imawn as tmmgt iiii, 
iever! where the powers of life are so seaiiy otcrwhebned, 
that the patient looks as if he were in the rdhpard staae of 
Asiatic cfaokral It b true that ia amay can of smpie ia 
termilteat ierer htondiHting has been praetni ia the coid 
2 • 



418 



Fallen on Congestive Fever. 



stage with advantage. But such cases are easy of explana- 
tion. They arise in persons who are laboring under an in- 
flammatory affection of some organ, and the congestion which 
ensues, as the result of deranged innervation during the cold 
stage, is accumulated upon this inflamed organ. In such 
cases, the increased hypersemia might be productive of bad 
consequences — and in such cases the system will bear the 
loss of blood, in accordance with the general law which 
establishes a greater tolerance of bloodletting whenever an 
inflammatory diathesis prevails. Thus we often see persons 
of a weak habit of body bear the loss of a large amount of 
blood in some acute inflammation, which they could not do, 
even in a state of health. 

In the present state of our knowledge it cannot for a mo- 
ment be supposed that the phenomena of congestive fever are 
owing to the deleterious effects of the venous blood accumu- 
lated in the viscera. Researches have proved that venous 
blood enables the nervous system and the various organs of 
the body to preserve their vitality much longer than when the 
blood has been entirely withdrawn, and therefore it cannot be 
poisonous to the functions of innervation, &c. {Influence of 
Physical Agents on Life, by Dr. W. F. Edwards). In truth, 
if the pathology of the disease be a lesion of innervation, 
the nervous system being in a state of sedation and irritation, 
it would be as rational to bleed in the oppressed stage of it, 
as it would be to bleed in a case of violent concussion of the 
brain before reaction came on. Bloodletting by diminishing 
the amount of the circulating fluid lessens the probabilities of 
reaction, and thus increases the danger. But after reaction 
is established, it may be necessary to withdraw blood under 
circumstances and in the manner presently to be described. 

The indication in the oppressed stage of congestive fever 
is, to rouse the nervous system so as to enable it to perform 
its functions. Remembering that although there is depres- 
sion of the vital manifestations, there is also an irritated con- 
dition, in which the nervous fluid is unequalised and misdi- 
rected, we must resort to those remedies whicli are capable 



Fallen on Congestive Fevpr. 



419 



both of stimulating and tranquillizing the nervous system. 
Steadily bearing in mind however the proneness of conges- 
tion to run into inflammation, we should avoid those stimu- 
lants which would be apt to create an inflammation after 
reaction came on. Fortunately however our art has afforded 
us remedies well adapted to this disease — and these are qui- 
nine and opium. The utility of opium in allaying the irrita- 
bility of the nervous system is well known. Its use in cut- 
ting short the cold stage of an intermittent is beyond doubt — 
quinine has powers of exciting the nervous system with but 
little danger of lighting up inflammation. In addition to 
these, it is proper to use the cold dash, frictions, &c., in the 
manner now to be described. 

If called to a case during the stage of depression, it was 
the custom of the writer to give about ten grains of the sul- 
phate of quinine with a grain or two of opium, to be repeated 
every two hours until reaction came on. If the stomach was 
too irritable to bear this, it was used in injection, taking care 
that the vehicle should be so small in quantity that it would 
be retained; at the same time endeavors were made to re- 
strain the irritability of the stomach by means of small pieces of 
ice (when it could be obtained), sinapisms to the epigastrium, 
the effervescing draught, &c. 

In addition to the method of reaching the nervous system 
by remedies administered internally, its peripheric extremi- 
ties so profusely spread over the cutaneous tissue were 
appealed to. With this view the cold dash was used. This 
remedy might seem in such cases less consonant with reason 
than bloodletting. To dash cold water over a person already 
so cold that his skin feels like ice might appear not rational. 
But when we remember how great an excitant to the ner- 
vous system the cold douche is, its efficacy will no longer be 
doubted. Hence if one falls into a state of S\'ncope, the first 
thing that suggests itself to the bystander's mind, is to throw 
cold water into the face. Hence too, when a patient is labor- 
ing under narcotism, the same remedy is universally used. 

The method of applying the cold dash is to place the pa- 



420 



Pal lea 07i Congestive Fever. 



tient on the floor and having a tub of cold water at hand, and 
taking a pitcher full, to pour a stream over him, from an 
eminence of about six feet, taking care to move the pitcher 
so that the fall of water shall strike the head, thorax and ab- 
domen, in rapid succession. Having continued this until 
signs of reaction are manifested, he is to be removed into bed 
enveloped in a blanket, and frictions are to be applied assid- 
uously all over the body. This may be done with the bare 
hand, or with a piece of flannel or the flesh brush dipped 
into spirits of turpentine. 

Under this treatment reaction is often established; if the 
stage of depression come on again, the same remedies are 
again to be used. 

When reaction is established we are to guard against in- 
flammation. Tliis does not often occur. If, however, the 
disease has been ushered in with diarrhoea, and there is ten- 
derness on pressure over the abdomen, the reaction is apt to 
be violent, and if not checked will terminate in a fatal col- 
lapse. Here is apt to arise a case complicated with enteritis. 
Under such circumstances we must rely on local blood-let- 
ling, emollient fomentations, and small doses of calomel, 
combined with opium and ipecac, administered at intervals 
of two or three hours. To this treatment the phlogosis will 
generally yield. Sometimes in persons of a plethoric habit, 
the brain seems to sufl'er after reaction. Here, the applica- 
tion of the cupping glass to the back of the neck, cold ap- 
plications to the head, sinapisms to the feet, and mercurial 
cathartics, will remove the symptoms. Having subdued the 
local irritation we resort to quinine in sufliciently large doses 
to prevent the recurrence of the paroxysm. It may some- 
times happen that we have reason to suspect local irritation, 
and yet dread the return of another paroxysm which may 
prove fatal. This happens in old persons, and in those of 
an enfeebled constitution. Are we to subdue the local irri- 
tation first and wait to give quinine? or to give the quinine 
before the local irritation is quelled? The writer's practice 
was, never to run the risk of a second paroxysm under such 



Fallen on Congestive Fever. 



421 



circumstances — as soon as the first one was oft' he gave 10 
grains of quinine, using at the same time extensive counter- 
irritation over the seat of the suffering organ. With this 
view a sinapism was applied until a deep redness of the 
skin was produced, and then a vesicatory was applied over 
the part. The quinine used in this manner never produced 
any bad consequences, whilst it averted the danger of a se- 
cond attack. 

In the large majority of cases, however, the period of re- 
action is not marked with any inflammatory condition. Our 
attention must be directed to keeping off" the return of the 
paroxysm. We of course then use quinine fearlessly, and it 
is well to commence as soon as the stage of reaction has 
come on; because quinine is not a difiusible stimulant, and 
requires some time before its effects on the system are felt — 
at least it certainly requires that it should have been intro- 
duced into the system some hours before its anti-periodic ef- 
fects are developed. In cases, therefore, which are not com- 
plicated with diarrhoea, we omit the opium given with the 
quinine in the stage of depression, and continue the quinine 
as before. 

If diarrhoea should be present, which is often occasioned 
by irritation in the ganglionic system of nerves, whereby the 
balance between the exhalents and absorbents is lost, and a 
large quantity of fluid is poured into the intestines, we must 
continue the opium. When the reverse happens, and we 
have costiveness, it is necessary to keep the bowels open 
with mild cathartics and enemata. After the period of the 
anticipated return of the paroxysm is passed, it is proper to 
allow the patient generous but not stimulating diet, and vege- 
table tonics; as his health suff"ers from the effects of the dis- 
ease for some time afterwards. 

April, 1843. 



422 Bayless on Pneumonia produced by Asphyxia. 



Art. IV. — A Case of Pneumonia produced by Asphyxia. 
By G. W. Bayless, M. 1.)., Demonstrator of Anatomy in 
the Louisville Medical Institute. 

On the 17th of October last, I was notified to attend an 
examination of the body of Brayer, at the Louisville Ma- 
rine Hospital. He was thirty-one years of age, had been 
laborer and boatman by occupation, and had generally enjoy- 
ed good health. It was said that both his father and mother 
had died of phthisis, but that no symptom of the disease had 
ever manifested itself in him. 

According to the account given by those who took him to 
the Hospital, he fell overboard from a steamboat at theVicks- 
burg landing, about the 26th of September. After remain- 
ing some minutes under water, he was taken out, to all 
appearances lifeless; he lay totally insensible for several min- 
utes, but, by some means or other, was finally resuscitated. 
He remained on the boat, which soon left for Louisville; and 
as he said himself, he was taken sick immediately. On the 
way, he had a dull pain in the left side, accompanied with 
cough and expectoration of some kind. He took no medi- 
cine on the way; the trip occupying about ten days. At the 
time that he entered the Hospital he was still laboring under 
the symptoms above enumerated, the expectoration being an 
opaque yellow mucus, sometimes presenting a rusty appear- 
ance. The ordinary physical signs of pneumonia, added to 
these functional ones, served to render the diagnosis of the 
case very plain. The treatment to which he vvas subjected 
in the Plospital, consisted of genera] and local bloodletting, 
blistering, the antimonial, and finally, I believe, the mercu- 
rial treatment. The above concise history of the case, is 
substantially that given by the attending physician, Professor 
Caldwell, just prior to the examination. 

AUTOPTICAL APPEARANCES SIX HOURS AFTER DEATH. 

Thorax. — Deposition of recent and imperfectly organized 
coagulable lymph over a great portion of the anterior part of 



Bayless on Fncumonia produced by Asphyxia. 423 



the left lung, producing slight adhesion. On the posterior 
part of the same lung there was also copious deposition of 
lymph, likewise recent, but more perfectlyorganized.and produ- 
cing a stronger adhesion. Very near the apex of this lung, 
on its anterior part, was a flattened and somewhat circular 
cavity, about an inch and a half in diameter, which contained 
about a teaspoonful of pus. It was essentially a pleuritic 
abscess, and its walls consisted of pretty firm false membrane. 
On the posterior part of the right lung there was likewise a 
deposition of recent lymph, but not so copious as on the 
left side, and the adhesion was not so strong. The right lung 
was greatly engorged with blood throughout, and there was a 
circumscribed portion about the size of the fist, near the 
middle of its back part, in a state of hepatization. Some 
small black spots, of an apoplectic appearance, were also 
seen in the same region. The left lung presented, in its 
various parts, all of the three stages of pneumonia. Its ante- 
rior and inferior portion presented the deep engorgmeht with 
blood flowing freely upon incision, and the sligh increase of 
solidity, characteristic of the first stage. Another part was 
in a state of hepatization; and the remainder presented the 
softening and purulent infiltration of the tissue of the lung, 
which characterizes the third stage.* At the upper and back 
part of this lung, about four inches from the top, was a cavi- 
ty about an inch in diameter, which was filled with dark 
venous and fluid blood. On three sides it was surrounded by 
a dark red, semi-solid substance, and on the other, by the 
pleura and false membrane only It was a well marked in- 
stance of interstitial apoplexy. Several small spots of the 
same kind were also seen in the same region. The heart was 
in a healthy condition. 

Abdomen. — No disease of any of its viscera. 

Head. — There having been no indications of disease in this 
cavity it was not examined. 



* This is according to Laeiinec and others. Stokes divides the disease into 
five stages. 



4'2-l Bayless on Pneumonia produced by Asphyxia. 

In presenting this case, it is by no means my purpose 
merely to show the ravages produced by inflammation on the 
surface and in the substance of the lungs; but to exhibit a 
somewhat rare instance of inflammation following asphyxia. 
I suppose that in this case, as is common in asphyxia, an 
accumulation of blood took place in the whole extent of the 
circulatory apparatus for venous blood; that from suspended 
respiratory movements, or from the failure of the unchanged 
venous blood (the air being excluded) to afford the proper stim- 
ulus to the radicles of the pulmonary veins, or from both these 
causes together, the accumulation commenced in these veins, 
that it then took place successively in the branches of the 
pulmonary artery, in the artery itself, the right ventricle, the 
right auricle, venae cavae, &c. Under this state of things, 
the right ventricle would necessarily (the exclusion of air 
continuing, and death not yet having taken place in the brain 
from its want of supply of arterial blood) force on its con- 
tents into the already distended pulmonary arteries, and the 
radicles of the pulmonary veins, until there should be pro- 
duced a very great engorgement, if not absolute rupture, of 
them. The individual being then removed from the circum- 
stances which brought on this condition of things, and respi- 
ration re-established, this engorgement of blood in the lungs 
would be dissipated slowly, and prove a source of irritation 
that would cause the development of all the inflammation and 
its consequences that we have seen. The congestion in this 
case, as the immediate consequence of asphyxia, was alto- 
gether different from that in ordinary inflammation in other 
parts of the body; and the inflammation was effected in a dif- 
ferent manner. When inflammation is setting up in other 
organs, or in the lungs from other causes, the congestion is 
in the nutritious vessels of the part; but in this case there 
was a deep engorgement of the pulmonary arteries and veins, 
as the immediate consequence of asphyxia, and this, by 
mechanical distention and consequent irritation, invited a 
secondary congestion in the ramifications of the bronchial 
arteries, which last led on to the inflammation and its con- 



Bayless nn Pneumonia produced by Asphyxia. 425 

sequences. As to the mode in which the various consequen- 
ces of inflammation, which we found, resulted in this par- 
ticular case, it would of course be superfluous to speak. They 
all took place in accordance with the well known laws of that 
morbid action. 

It may be asked, did not the individual take cold, and was 
not the pneumonia produced, as ordinarily, by the impress 
of that agent? I reply, that two circumstances in the history 
of the case induce me to think not. First, that the accident 
occurred at a season of the year when pneumonia is not read- 
ily produced in a stout man by such an exposure to cold. 
Secondly, that he was taken sick immediaielij , which would 
not have been the case if cold had been the agent in the pro- 
duction of the disease; whereas the congestion of the pulmo- 
nary vessels is quite sufficient to account for his immediate 
indisposition. 

May, 1843. 



3 



iStfiHoflrapfucal Notices. 



Art. VI. — A Practical Treatise on Venereal Diseases; or Crit- 
ical and Experimental Researches on Inoculation applied 
to the Studij of those Affections, with a Therapeutical Sum- 
mary and Special Formulary. By Pn. Ricord, M. D., 
Surgeon of the Venereal Hospital of Paris, Clinical Pro- 
fessor of Special Pathology, &c. Translated from the 
P'rencli by Henky Pilkington Drummond, M. D. Phila- 
delphia, Lea and Blanchard: 1843. pp. 256. 

Few members of the profession, who keep pace with its 
literature and its improvements, are unacquainted with the 
name of Ricord, in connexion with venereal diseases. By 
well directed study, and a series of happy experiments, he 
has done more perhaps ihan any living writer towards 
removing the obscurity that reigned over many important and 
interesting questions connected with those affections. As 
the result of his labors, we have a more rational pathology, 
a more exact diagnosis, and an improved system of therapeu- 
tics. 

We have here his views presented in an English dress, 
which cannot fail to prove highly acceptable to the profession. 
Dr. Drummond has acquitted himself very well as a transla- 
tor; for we have reason to know that the author's style pre- 
sented great difficulties. Had he adhered less closely to the 
original, the translation would have been freer from certain 
gallicisms and redundancies; but it is clear — and that is suf- 
ficient. C. 



Lawrence on the Eye. 



427 



Art. VII. — A Treatise on Diseases of the Eye. By William 
Lawrence, F. R. S., Surgeon Extraordinary to the Queen, 
Surgeon to St. Bartholomew's Hospital, &c., &c. From 
the last London edition. With numerous additions and 
sixty-seven Illustrations. By Isaac Hays, M. D., Surgeon 
to Will's Hospital, &c., &c. 

This is a very beautitul book, and is, without doubt, the 
most splendid treatise on the subject in the language. We 
know of nothing equal to it, and we hope that it will 
meet with a wide circulation. Affections of the eye are too 
much neglected by the profession generally; the subject is 
very inadequately discussed in the majority of our schools, 
but one or two of which have a chair devoted to ophthalmic 
medicine and surgery; in all the others it is despatched in 
about a half-dozen lectures. In the west at least, these dis- 
eases are not infrequent — in certain districts, unless we mis- 
take, they are very frequent; and a little more attention de- 
voted to their study, might save the unfortunate from the ten- 
der mercies of the stationary or itinerant "eye-doctor," and 
from that direst of all calamities, total and irremediable blind- 
ness. 

The following quotation from the very short preface of the 
American editor, will show what alterations and improve- 
ments have been made in the present edition. 

"The present, is a reprint from the last London edition, 
which appeared in 1841, completely revised and greatly en- 
larged by the author; and to it considerable additions have 
been made by the Editor. 

"Sixty-seven illustrations are introduced, many of them 
from original drawings, the whole engraved by Mr. R. S. 
Gilbert. 

"Several subjects omitted in the original, are treated of; in 
supplying which, as well as on other occasions, free use has 
been made of the valuable Treatise of Mr. McKenzie. The 
catoptric examination of the eye, and its value as a means of 
diagnosis; the recent investigations into the structures of the 
orbit, &c., are all fully considered." 

' The reader must not suppose from the modest manner in 



428 



Lawrence on Ruptures. 



which the editor thus speaks of his own labors that they are 
few or unimportant; they contain, what is of no small value, 
"the results of his experience in relation to the treatment of 
most of the important diseases, derived from more than 
twenty years devotion to the subject, during all which period 
he has been attached to some public institution for the treat- 
ment of Diseases of the Eye." C. 



Art. VIII. — A Treatise on Ruptures. By W. Lawrence, F, 
R. S., Surgeon extraordinary to the Queen, &c. From the 
fifth London edition. Revised, corrected and enlarged, 
pp. 480, 8vo. Lea and Blanchard; Philadelphia, 1843. 

This work is no less excellent than the former by the same 
author, and, like it, has long since taken rank as one 
of the very highest authority. Both of them indeed bear 
the impress of the accomplished and well-stored mind 
from which they emanate. There is a completeness and a 
finish about the productions of Mr. Lawrence (conspicuous 
in both these works) rarely to be seen in those of any other 
writer. His extent of learning and research — all of ancient 
and modern medical literature being thoroughly searched for 
materials — is unequalled; and all thus collected, is compact 
in that singularly felicitous style, for which he is remarka- 
ble. He gives you all that is known on a subject — all that 
has been said or written ahout it, not crudely and undi^^est- 
edly, but after having well weighed its merits, his opinion 
of which he does not hesitate to express. These are the 
labors that possess true value, and that must endure. 

The corrections, revisions and additions, mentioned in the 
title, were made by the author to the fifth edition published 
in London. C. 



Proceedings of the Medical Convention of Ohio. 429 



Art. IX. — Proceedings of the Medical Convention of Ohio, 
held at Cincinnati on the I6th, I7th, ISth, 19th, and 20th, 
of May, 1S42. With selections from papers read before 
thai body. Cincinnati, R. P. Brooks, 1S4'2. pp.51. 

We observed in the Journal for April that, of the vari- 
ous papers presented to the Convention, but two were pub- 
lished. The first and longest of these, is entitled "A History of 
the Topography, Climate and Diseases of the County of Scioto, 
from its settlement to the present time." In the outset of 
this paper, the author. Dr. Hempstead, pays a well deserved 
tribute to the hardy and enterprising men, who led the way 
in the settlement of the country, and he acknowledges his 
indebtedness to them for much valuable information regard- 
ing the diseases of the early inhabitants. Doubtless much 
might still be gleaned in this way — as these individuals, 
otherwise of acute and retentive minds, were oftentimes com- 
pelled to be their own physicians. 

Dr. H. thus describes the region of country to which his 
observations refer: 

"The county of Scioto is situated upon the southern border 
of the state, at the confluence of the Scioto and Ohio rivers, 
and in Lat. 33= 38" N., and 82° 56" W., extending North 
about twenty miles, and including the table land for twenty 
miles East and West on either side of the Scioto river. The 
valley proper is based on a bed of shale, which may be seen 
cropping out a few miles below Portsmouth, and disappears 
not far from the western line of the county, near the great 
western limestone deposit. The table land is here elevated 
from three to five hundred feet above the surface of the valley. 
It is gently undulating, but as it approaches the Scioto it be- 
comes very precipitous, and, in most places, incapable of 
cultivation. The tributaries of the Scioto, which arise in this 
region, are very rapid, highly charged with lime, and subject 
to great alternations from the most rapid and violent torrents, 
to the most perfect destitution of all moisture. On the east 
side of the valley, the surface is not so high by two hundred 
feet. It also rises less abruptly than on the west. Still, it 
is undulating, and affords fine grazing and arable farms. The 
water courses, however, are not so numerous as they are on 



430 Proceedings of the Medical Convention of Ohio. 



the opposite side of the river. Iron, coal, and saliferous rock 
are found in this locality, which is bounded on the east by 
the buhr-stone deposit. Out of the valley proper, no ponds 
or stagnant waters are found, the vegetation is less luxuriant, 
and of a more durable and ligneous character, than that found 
in the alluvions immediately bounding the Scioto. Between 
the low bottoms and the river hills, sandy blufis occasionally 
occur, composed principally of coarse gravel and sand, with 
a very thin vegetable mould, soon exhausted by cultivation, 
and when the soil becomes impoverished, it is not easily re- 
newed, especially as these blufls are too high to be benefitted 
by the spring floods, which annually inundate and enrich the 
low grounds. Upon these blufls, elevated from ten to forty 
feet above the highest floods, are found those monuments of 
a race long since departed, but still exhibiting, by their 
works, the strongest proof of having been a populous, an 
industrious, and a talented people. These evidences of a 
laborious, intelligent, and, to some extent, a civilized com- 
munity, are to be found, at short intervals, upon either side 
of the Ohio and Scioto rivers, occasionally extending into 
the valley, but occupying ground above all ordinary floods. 
The soil west of the Scioto is good, containing a portion of 
sand, and possessing the characteristics of a calcareous de- 
posit. Elevated from four to six hundred feet above the val- 
ley, it descends towards the east, exposing the limestone, 
waverly sandstone, and slaty argillacious rock, which last 
underlies the valley proper. From this point the surface 
rises some three hundred feet, changing its character, and be- 
coming a pure clay. Although more broken by hills, and 
less suited to agriculture, it is rich in mineral wealth. 

"The valley of the Scioto, from two to five miles in width, 
possesses a soil unsurpassed in fertility and durability by any 
other; being composed of the debris and washings of the 
uplands, with a large mixture of decayed vegetable matter 
deposited by the spring floods which aniuially inundate it. 

"The southern border of this locality, comprising the val- 
ley of the Ohio, differs but little from the alluvions of the 
Scioto; since the low bottoms of the former, which are fre- 
quently inundated, |)ossessall the fertility and durability of the 
latter, while the high or "second bottoms." which are mostly 
argillaceous, are less productive, being destitute of that rich 
arenaceous deposit, which annually renews and ameliorates 
those less elevated. The table land of the region now under 
consideration is covered with all the varieties of the oak, 
except the highest points, which contain groves of pine. The 



Proceedingt. of the Medical Convention of Ohio. 



431 



slopes connecting the bottoms with the upland exhibit a gen- 
eral mixture of western trees, including the locust, pawpaw, 
sugar tree, &c., while the sycamore, cottonwood, black wal- 
nut, mulberry, maple, an,d elm, occupy the lower portions of 
the valley. There is not much undergrowth, except in the low 
valley, which consists of a luxuriant production of annual 
plants, that are constantly decomposing and enriching the soil 
upon which they grow.* The Ohio interval produces beech, 
hickory, and rnaple, with sycamore and elm on the margin of 
the stream." 

The inhabitants of this reijion a'e supplied with water 
from the Ohio and Sc;ioto rivers, and their tributaries, and from 
wells and springs, whit:h vary on dillercnt sides of tiie val- 
ley. 

"On the east side of the valley, fine springs of soft, whole- 
some, and pleasant water, like that of the Ohio river, above 
its junction with the Scioto, are (bund in abundance, free 
from iron or other minerals. The wells in their vicinity are 
of the same cliaracter, while the springs and wells west par- 
take of the character of the country in which they are situa- 
ted, being, like the water of the Scioto, strongly impregnated 
with calcareous matter." 

He mentions the following singular circumstance, which we 
do not remember to have seen noticed elsewhere. 

"A singular and interesting circumstance, connected with 
the ancient works in Portsmouth and its vicinity, affecting 
some of its wells, deserves here to be mentioned, and rnay 
throw some light upon the uses for which at least some of 
those embankments were constructed. North ol' the east 
end of the town, on a sandy elevation of some two hundred 
feet above the Ohio bottom, the construction of which has 
much the appearance of being artificial, are found two paral- 
lel embankments, which descend to the sayid bluffs before 
mentioned, and then pass down to the Ohio bottom, where 
it is elevated from three to seven feet above the highest known 
flood. These embankments, continuing on the same eleva- 
tion, enter the corporation at its east end, and pass through 
the north part of the town to the Scioto river, where they are 



* The writer, some ten or fifteen years since, frequently passed through tliis 
undergrowth. When on horsel)ack, he was unable to reach, witii a common 
riding-whip, the top of a growth of vegetation standing so thick over the uncul- 
tivated portions of the valley as entirely to exclude the sun. 



432 Proceedings of the Medical Convention of Ohio. 



lost, evidently from the encroachments of that stream, for 
they again appear some dislance below, and terminate on the 
bank of the Ohio, a short distance above the present mouth 
of the Scioto. Upon, or very near to these embankments, 
which vary from three feet in height to almost entire oblitera- 
tion, a number of wells have been sunk to the depth of six- 
teen feet, furnishing an abundant supply of water, as pure as 
the mountain rill, being filtered through the fine sand, 
which is deposited by the Ohio when it overflows its banks. 
The wells which are located four or five rods north or south 
of tiiese embankments pass through the natural clay of the 
bottom, from fifty to sixty feet, before a full supply of water 
can be obtained. It would seem that two intrenchments had 
been excavated in the clayey soil at least sixteen feet deep, 
and then filled with sand. The compact character of the clay 
confines the water, while the sand supports the clay walls, 
and permits the water to filter through. Whether this water 
is conducted from the hills, or collected between the embank- 
ments from rains, has not yet heen satisfactorily ascertained. 
Jn its sensible properties, it is like thai of the springs at the 
foot of the hills, upon which the embankments commence. 
Half a mile east of the town are some mounds, and an eleva- 
tion, of the same sand, comprising about two acres, including 
the embankments. This sandy elevation h;is a number of 
springs around its margin, some of which rise to the surface; 
others are found in three or lour feet excavation, a thing 
unusual on the Ohio bottoms. The writer has a spring in his 
cellar, from the same source, (although he is located more 
than thirty rods from the embankment), which rises to within 
four feet of the surface. It is two feet deep, and occasionally 
disappears in very extreme dry wrather; while the wells, as 
before stated, never sink more than six feet below the sur- 
face, and frequently run over the top." 
Mineral and medicinal springs abound. 

"Those of the cast side of the valley contain salt and iron, 
pctroleumor bituminous oil; and one deposits, Ibr two or three 
rods from its origin, a substance as white as snow, supposed 
to be magnesia, InU more probably sulphate of lime. The 
chalybeate springs holil iron in sucfi minute divisions as to 
be well suited to those cases of excitable debility which fre- 
quently occur and are often aggravated by any of the phar- 
macological forms of this tonic. These springs have been 
resorted to with much and decided benefit; they are gene- 



Proceedings of the Medical Convention of Ohio. 433 



rally situated in a mountain region, liigh, healthy, and among 
the furnaces, where novelty, exercise, and amusement, are 
notwantint^. The springs of the western or limestone region 
are occasionally charged with sulpliur, soda, ina;j:nesia, iron, 
and other salts. On ihe waters of Brush creek, about lour or 
five miles from the Scioto valley, around the margin of an 
elevated portion of glady country, a number of medicinal 
springs are found, containing a variety of salts, and differing 
sowewhat in character froifi each other. As lliese are situa- 
ted in a region unsurpassed for romantic scenery, above mi- 
asmatic influence, and possessing the finest hunting and fish- 
ing ground in the State, they may, at no distant period, be- 
come a desirable resort for health and amusement." 

Sulphuret and sulphate of iron are found in great quantity 
on the west side of the valley near the Ohio. In the sum- 
mer of 1839, he witnessed an interesting phenomena. "The 
rocky bed of the creek had been dry for some time and ex- 
posed for many days to a temperature above 90°, when a 
number of explosions occurred from the expansion and erup- 
tion of large masses of very pure pyrites, imbedded in the 
solid rock, leaving excavations indicating the boulder of sul- 
phuret of iron to have been from twelve to eighteen inches 
in diameter." 

That magnificent public work, the Ohio and Erie canal, 
passes through this county. When it was first projected, 
fears were entertained that the ponds and pools created by 
it would exert an unfavorable influence upon the health of 
the inhabitants; but these fears proved groundless. 

"A careful observation for the last nine j'ears in the vicini- 
ty of this improvement, has not detected any additional ma- 
larious influence, any increase of disease, or any new ailment 
affecting in any way the health of the inhabitants, excepting 
during the autunm when the excavation was going forward, 
at which time it was visited with an unusual amount of dis- 
ease. This latter circumstance was also peculiarly apparent 
in 1840 and 1841, upon that part of "the Portfimouth and 
Columbus turnpike" which runs through the same county, 
especially where excavations and embankments were progres- 
sing during the fall months. In consequence of accidents, or 
to make repairs, the water of the canal has been repeatedly 



434 Proceedings of the Medical Convention of Ohio. 



drawn off at the most unfavorable season, exposing an exten- 
sive slimy and foul surface to the action of an autumnal sun, 
until all moisture has been dissipated, and yet no deleterious 
influence has been the result. So far from this being the case, 
a single incident in 1837 goes to show an opposite effect. 
The ordinary diseases of the summer had been rather preva- 
lent in the immediate vicinity of the canal, and a considera- 
ble number were then sick. On the 8th of September the 
water was drawn olf, and the writer is confident that six new 
cases did not occur in that vicinity, for the balance of the 
season." 

A portion of this region is subject to inundations from the 
Ohio and Scioto rivers; these were more frequent from 1795 
to 1820, than they have been since. The differences in the 
diseases of the river bottoms, and of the uplands covered with 
forests, are striking; the purely miasmatic being confined to 
the former or inundated portions, while a different class occu- 
pies the higher regions. 

The following picture of the habitations and manners of 
the early settlers, is true to the life. 

"The residences of the early settlers were, as at the pres- 
ent day, on the banks of the streams, or on the slopes con- 
necting the bottoms with the upland. They were built of 
logs, and well ventilated, not by windows and doors, but by 
the interstices between the logs. They were also occasion- 
ally washed by rains dashing through the impeifcct covering. 
These walls, with an opening in the roof for smoke, and an 
earthen or puncheon floor, completed the domiciliary com- 
forts of the early pioneer. Their scanty and thin clothing 
protected them still less against "the peltings of the pitiless 
storm,'' than their open and uncomfortable cabins. It was 
no uncommon occurrence for an individual to pass the win- 
ters of that period, with no other outer garments than the 
I)ataloons and hunting shirt, and these of the thinnest fabric of 
cotton and wool, the bare thoughts of which at the present 
day would cause a shudder at almost any season. The diet 
of this hardy race was in keeping with their other comforts. 
The fruits of the chase, a few vegetables in their season, and 
coarse cakes, prepared from meal ground upon the invalua- 
ble, ever revolving, and never idle Aanrf-wizV/, constituted their 
whole bill of fare. Their amusements corresponded with 



Proceedings of the Medical Convention of Ohio. 435 



iheir hardy character. These consisted in aiding a neighbor 
to husk his corn, to raise a cabin, to roll his logs; or among 
the females, to quilt a quilt; at which as well as at most other 
assembhes a bottle of ''Monongnhelu" was a universal accom- 
paniment. Alter the work was done, shooting at a mark, 
pitching quoits, wrestling, jumping, dancing, and by way of 
accommodation an occasional game of "l ough and tumble," 
filled up the balance of the day and part ot" tlie night." 

Tlie climate of this region, like all in this great valley, per- 
haps we might say all on the western shore of the Atlantic, is 
subject to great and sudden alterations. 

"The changes are very sudden and rapid, not nnfrequently 
varying the temperature forty degrees in twelve hours, and in- 
stances have been noticed in which a change of fifty degrees 
has occurred in eight hours. For want of a series of obser- 
vations sufficiently extensive no fixed character can, as yet, 
be given to our climate, although this desideratum will no 
doubt.be soon obtained if the regulations established by the 
Surgeon General of the army be faithfully and carefully com- 
plied with at the several military posts. A sufficiency, how- 
ever, is known to establish the fact that for some years past 
our seasons have been changing. Previous to 1820 the win- 
ters were not so cold, nor the sunimer so warm as they have 
been since that period, and particularly since 1S30, which 
was the first time for some years that the thermometer was 
below zero. From the settlement of the county in 1795, the 
winters were mild, with a few days of severe weather, while 
the summers were cool, with an occasional day of elevated 
temperature. And although there has been manifestly a 
change, as will appear by the abstracts accompanying this 
paper, yet the mean temperature for the year was greater be- 
fore than since the period mentioned. The mean tempera- 
ture of the six years preceding 1 830 being 55-45, while the 
six years since were but 5-4-75. So far as any statistics of 
the weather can be obtained, the mean temperature of the 
year, or of the hot or cold months, has not materially dilTered 
since the settlement of the county. The same remark will 
apply to the amount of rain; but the fogs, winds and violent 
storms, have undergone a very great change. From the first 
settlement of the county to 18i0, the fogs usually commenced 
early in July, were very regular in their daily appearance, 
suspended only for a night or two previous to rain. They 



■136 Proctedings of the Medical Convention of Ohio. 



generally were observable as early as 9 o'clock, P. M., and 
frequently continued till the same hour the next morning, and 
occasionally till 11 o'clock, being throughout very dense and 
loaded with moisture. It was not unusual to see, during a 
dense fog, the water fall from the leaves of the trees like a 
shower of rain. These characteristics of the fogs of that 
period did not undergo much sensible change until '26 or '27, 
since which they fall later in the night, frequenly not till near 
day light in the morning, and are with few exceptions dissi- 
pated by 8 o'clock A. M. The amount of moisture has 
greatly decreased, and it is not unusual for fogs to disappear 
during the summer and autumn for nights in succession, or 
to be seen only in the valleys and on the immediate neigh- 
boring hills. Their eftects, whatever they may be, are not 
of course observable, upon the higher and more elevated re- 
gions. The prevailing winds of the first twenty-five years 
were westerly. In 1838, an ordinary observer must have dis- 
covered that they were decidedly on the decrease. In 1838 
the easterly were to the westerly as one to two, in '39 and '40 
nearly balanced, and in '41 were decidedly the prevailing 
wind of the year. The writer is well assured, from the 
authority of others, and partly from his own observation that 
from the year 1800 to 1810 no fall of rain was attended by 
an easterly wind. From that period to 1820 this wind was 
steadily and gradually on the increase, and from '21 onward 
has been observable, occasionally throughout each year. For 
the last twenty years those violent tornadoes, accompanied 
by thunder, which formerly swept so frequently through our 
State, have become less frequent and violent, and for the last 
few years have nearly disappeared. Hail, which attended 
them particularly in the month of June, is in this region an 
uncommon occurrence; very few storms of this kind having 
been observed in the last ten years. Electrical phenomena 
have also disappeared with the decrease of tornadoes and the 
increase of easterly winds. The hygrometrical observations 
have been so few that no comparati'-e estimate can be made 
of former and latter years; yet a sufficiency is known to make 
certain one point, that no epidemic meteoration or any con- 
siderable prevalence of disease has ever occurred in a dry 
atmosphere, but are invariably accompanied by one loaded 
with moisture. Another fact is also developed, that a high 
hygrometric state of the atmosphere does not depend on the 
amount of rain, hence the fact that extensive disease has 
occurred in very wet, dry and medium seasons." 



proceedings of the Medical Convention of Ohio. 437 



During the prevalence of epidemics, or any unusual amount 
of sickness, the north winds have been observed to augment 
the number of cases. This might be attributed to their pas- 
sage over the miasmatic regions of the valley, if the same 
effect was not observed in connection with the easterly winds. 
Dr. H. reconciles this difficulty by supposing that a predispo- 
sition to autumnal disease is produced by the westerly winds, 
which traverse the malarious portion of the valleys of both 
rivers, and that the winds from the north and east act as ex- 
citing causes from other qualities that they possess besides 
malaria. Assuming malaria to be the cause of the fevers of 
this region, it is a little singular that its received sources have 
been steadily diminishing, whilst the diseases attributed to 
it are far more prevalent. And from facts in his pos- 
session, Dr. H. doubts whether the sources of miasm are cor- 
rectly understood, and urges renewed inquiry. 

"To identify this all-pervading influence, to give it a local 
habitation and a name, are efiorts worthy the united energies 
of the medical community. And how long shall we be con- 
tent to know it exists only by its effects, and rest satisfied in 
counteracting those effects, while we are entirely ignorant of 
the first principles of the cause which produces them? It has 
been urged, yea settled, that heat, moisture, and dead vegeta- 
ble matter, will invariably produce this deleterious agent; yet 
how often do we find the predictions of physicians fail, even 
when these agents appear to be present, and under the most 
favorable circumstances for the generation of this aerial poi- 
son. At other times, when the temperature, moisture, and 
vegetable matter, would seem to indicate a state of atmos- 
phere as pure as the mountain breeze, our pleasing anticipa- 
tions of health and ha])piness are blasted by the deadly 
simoom of the autumn, which, like the wind, "bloweth where 
it listeth, and thou liearest the sound thereof, but canst not 
tell whence it cometh or whither it goeth;" at one time deal- 
ing death and destruction in the high and elevated regions of 
health, at others sweeping with fearful strides through the 
lower and more fertile but less salubrious valleys." 

Among the diseases incident to this region, intermittent 
and remittent fevers of course hold a prominent place. These 
4 



438 Proceedings of the Medical Convention of Ohio. 



are, indeed, the only diseases to which the early settlers were 
liable; they usually began about the last of June and con 
tinued till the last of October, the remainder of the year being 
healthy. "An epidemic meteoration" has been observed five 
times— in 1807, '21 , '22, '23, and '24. The epidemic of 1807 
was very general, embracing the entire valley of the Ohio, and 
many ofits tributaries, and involvingnearly the wliole population, 
many of whom died of the disease, or of improper treatment. 
This disease corresponded to the remittent fever described in 
the b )oks; it appeared occasionally up to 1820. That of 
'21 was at first a bilious remittent fever, which after the 1st of 
August changed to an intermittent, and was more fatal. The 
epidemic of '22 was a double tertian intermittent, and pre. 
vailed generally in town and country. That of '23, was not 
violent and prevailed mostly in the town. That of 1824, 
also a double tertian, was entirely confined to the town, and 
was unusually severe. 

Since these epidemics, the diseases of this region have 
greatly increased in variety, and occur throughout the year 
save in April and May, which are generally healthy. 

Bilious pneumonia was first observed in March 1824, has 
since recurred every year from December to March, and was 
epidemic in the winter and spring of '26, '29, '31, '3G, '38, 
'40, '41, and '42. Intermittent cephalalgia is common, at 
times aflfecting a large part of the population. Rheumatism 
both acute and chronic is very rare; Irom 1816 to 1838, Dr. 
II. did not see more than ten cases; since the latter period 
it has increased, and since 1841 has been very common. All 
the cases were attended by fever of the intermittent type; in 
many instances it was succeeded by chorea. Dr. 11. relied 
chiefly on the alcoholic tincture of the actea racemosa, which 
he tiiinks as valuable in chorea and rheumatism, as quinine 
in intermittents. He likewise uses it in neuralgia, some 
forms of diseased liver, and in rigidity of the os uteri. 

Previous to 1812 cholera infantum was unknown; after 
the year 1821, it became quite common, and was extremely 



Proceedings of the Medical Convention of Ohio. 439 



fatal; declined after 1830, until 1841, when it was again very 
fatal. 

Of the exanthemata, Dr. H. notices small pox, measles, 
hooping-cough; scarlet fever and mumps, as having prevailed 
at different times. These spread much more generally on 
the uplands than in the valley, where they seemed to lose in 
a great measure their contagious character. This last is also 
true of Asiatic cholera, which appeared in '32, and again in 
'33 and '34. 

Croup and quinsy are uncommon — in 25 years not more 
than ten cases have been witnessed in the Ohio and Scioto 
valleys. Gangrenopsis is rather frequent, always affects deci- 
dedly scrofulous constitutions, occurs in the autumn, and 
generally at the close of protracted diseases. It owes its 
origin to the same causes that produce intermittents, and 
vpas most prevalent during the epidemic years. Phthisis pul- 
monalis is rare; an original case has never occurred in this 
locality, though scrofula in some of its forms is common. 

Dr. H's paper closes with abstracts of thermometric obser- 
vations from 1824 to 1835 inclusive; and of thermometric 
and barometric observations from 1835 to 1841. These ob- 
servations were conducted by himself, and are evidently 
drawn up with great care. But we have already consumed 
a good deal of space in this notice — more perhaps than some 
of our readers may think warrantable; if we shall but incite 
to further observations of the kind, our object will be accom- 
plished. It is only by the accumulation of labors of this sort, 
that medical histories of extended regions can be known; he 
who asks the cui bono, is not likely to understand it if he were 
told. 

The other paper in these proceedings is on "the causes and 
treatment of Milksickness," by Dr. Dawson, and was pre- 
pared in ohedience to a resolution of the Convention at its 
previous meeting. So much has appeared in the Journal on 
this subject, that we fear some of our readers feel a degree of 
nausea at the bare mention of it. We will take this opporlu- 



440 Proceedings of the Medical Convention of Ohio. 

nity, however, to express our own disbelief in any such disease. 
We were brought up in a region where it is believed to be 
present, where Dr. Seaton and others say it prevails (though 
the former errs in the geological formation of the country); 
but we never could satisfy ourselves of it. We have seen 
what was called milksickness; but it was nought else than a 
form of remittent fever, and was amenable to the same reme- 
dies. We have seen all the phenomena of the so called 
milksickness produced by worms, and cease on their expul- 
sion. We never knew an instance that could be traced to 
milk, butter or beef— and we doubt very much if one ever 
was or ever will be. We do not deny that the beef, milk, 
&c., of sick cattle will produce disease in man, but we do 
not believe that it produces in certain districts, and no others, 
milksickness. Even if it did, it is made a much greater bug- 
bear than there is any necessity for. Its prevention is easy, 
far more than that of most other diseases, and its attacks are not 
more fatal. Men rush unconcernedly into regions where the 
very air is thick with the elements of death, but they fly as 
from some horrid and wide-wasting pestilence the region where 
milksickness is said to prevail. Our opinion has not been 
formed lightly or hastily — and we believe, that if it is not now, 
it will be sooner or later the sentiment of the profession. 

The convention was in session five days, and a large amount 
of business was transacted. Of the various exercises, it would 
be somewhat late to speak, seeing that twelve moons have 
passed since it adjourned. It is the less necessary too, from 
the notice, embracing the more important matters, given by 
us shortly after the adjournment. 

At an early period of the sitting, those who knew the secret 
sources of action, who could pierce to the under-currents 
that flowed hither and yon, feared for the harmony of the 
convention. There were old feuds at work, secret heart- 
burnings and jealousies, wounded pride, and peradventure 
wounded feelings. And so new animosities were engen- 
dered by the old; factions multiplied; parties were formed; 
bitter words and keen retorts passed from man to man; 



Proceedings of the Medical Convention of Ohio. 441 



and anger and pride were about to do' their work. But 
a few mild words from one who had borne the toils of some 
forty summers and winters among that people, whose name 
is identified with their history, and with that of the profession 
in the west — words which were as true-hearted as they 
were few and touching — stilled the rising storm, dispelled 
as if by magic the ominous and surcharged clouds that were 
gathering for elemental play around and over-head, and then 
peace like a dove 

came forih to spy 

What calm had fallen on earth, what light was m the sky! 

Explanations were made — a reconciliation took place; old 
injuries were mutually forgiven and forgotten; hands that 
erewhile were clenched in passion were now clasped in 
friendship — what if cheeks lately flushed with anger, were 
bedewed with tears from eyes all unused to them? — and now 
the profession in that state presents, so far as we know, an 
unbroken and undivided front, one in interest, purpose, and 
feeling. Is it so in any other State in the Union? C. 



X 



Selections fvom ^mem'can antr iForet'sii Jountals. 



Presumption of Survivorship. — (Continued from page 352.) 
Thirdly. When many persons perish at the same time by 
drowning. 

The following circumstances are to be taken notice of ia 
cases of this kind: 

1. Persons, who are able to hold their breath a long time, 
will die later than those who cannot. Col. Townshcnd placed 
himself in the presence of many physicians in a state resem- 
bling death. He laid himself upon his back, one physician 
felt his pulse, another beating of the heart, the third held a 
mirror before his mouth. Pulsation and beating of the heart 
ceased instantly, the mirror remained clear, this state con- 
tinued for half an hour, when the beating of the heart and 
respiration returned. {Henke^s Zeitsckrift, 4 Jahrgang). 

2. Persons who fall head loremost into tlie water, will die 
earlier than those who fall in another manner. 

3. Persons who remain longer upon the surface of the 
water, or several times rise up again, will die later than those 
who sink immediately to the bottom. 

Dissection of such drowned persons afiords the principal 
grounds of decision, whether they have lost their lives by 
apoplexy or suffocation. 

Apoplexy causes death sooner than suffocation. But should 
many persons have died of apoplexy or suffocalion, we may 
certainly assume, that the persons with whom a tendency to 
apoplexy prevailed, have died sooner than those where this 
was not the case. With persons inclined to apoplexy, death 
on falling into the water^ particularly if they are heated, 
occurs instantly." {Henke's Leitrbuch, § 473). 

But where many persons have died at the same time of 
suffocation, we may assume, that the persons on whom the 
signs of suffocation are the most distinct and marked, have 
died last. 



Presumption of Survivorship. 443 



A body, on which the signs of suffocation and apoplexy 
are found at the same time, has died earlier than one on which 
we find merely the signs of suffocation. 

A lady of noble birth, E. M. v. L. was passing with her 
three daughters, of 14, 16, and 18 years of age, and her cook 
in a two horse-coach through the ford at Pradel, which was 
very much swollen: the king-bolt of the carriage came out 
and the horses drove on with the fore part of the carriage. 
The back part sank down, and was carried somewhat forward 
by the water, whereupon the coachman springs from his seat, 
in order to assist the persons sitting in the carriage, but 
which was impossible, as the water in the stream carried the 
carriage across and overturned it, which he did not let go of, 
and thought to keep hold of, which liowever was impossible, 
because he, at the time when the carriage was turned over, 
was turned over with it. When the carriage had been turned 
round some three times, they were all slill alive; but when 
the carriage rose up the fourth time, the three young ladies 
were already dead, the lady and the cook were still alive, 
while the first three were fallen down, and did not move, and 
had also partly fallen out backwards: the cook had still cried 
out, and the lady said to him, Oh! coachman save yourself 
only; as he had then at three dillerent times been drawn by 
the current under the water. When the water had again 
turned over the carriage, the lady yet cried out and prayed; 
but after that the coachman had seen no one again, and was 
himself forced on by the current, until he came to a tree, 
which he seized. 

When now the maternal relations claimed the whole inher- 
itance, to the exclusion of the paternal relations, the latter 
sought to invalidate the testimony of the coachman, and based 
themselves upon the presumption of law, that the children 
might have lived longer than the mother, and if not all, yet 
at least one had survived the mother. Upon this very doubt- 
ful case the following questions were propounded. 

a. Whether from all the occurring circumstances, that, 
what the coachman has testified of the first ensying death of 
the three daughters, deserved credit, and that theret'ore it was 
to be held probable that the mother survived the daughters. 

This question was thus answered: although ex actis it does 
not appear, who had drawn the drowned bodies from the 
water, how soon it was done, whether any one was near by, 
and had traced motion, respiration, warmth, or any signs of 
life, on any of the bodies; also that the fishermen, who were 
in the neighborhood, or any others iiad been examined; fur- 



444 



Presumption of Survivorship. 



ther, the coachman has not explained what he meant by 
springing from the seat, how, and where he had stood, that 
he possibly would have held on the wagon, and had perceived 
what had taken place therein, as he h;is related it: besides we 
* do not find how old the drowned lady V^on L. was, hence we 
had to investigate the point. But since the answer to the 
proposed question, first concerns that, what the coachman 
could perhaps immediately perceive, and judge of according 
to the circumstances and als6 to the appearances, but especi- 
ally to the others, how such things might deceive, and he not 
be able to know the real death of the three ladies; yet from 
the legal documents we may believe, that the bodies were 
drawn out from the water as soon as possible, that no sign of 
it was observed in either, while an evidence of that kind 
might have decided the whole question, and it is well re- 
marked, that tiie coachman, at the time he observed what 
was taking place with and in the coach, had his head above 
the water, also from the age of the young ladies, the age of 
the mother was about 40, more oi" less. 

Hence in reference to the first point of the answer: it is so, 
that in the anguish and d.mger of death, wherein the coach- 
man found himself, he could with difficulty observe the course 
of things, and it is not indeed possible, that he from the falling 
down, and want of motion, at such a moment could correctly 
decide, whether the ladies, especially three of them, together * 
with the mother and the cook who were in the coach, were 
really dead, still from the testimony of the coachman, that 
the lady had spoken the last, and on the fourth turning of the 
carriage the daughter had fallen down, and did not move; we 
hold it probable, that in so far as it can appear from the 
coachman, it must be, that the three ladies had died before 
the mother. 

But this account of the evidences of death, uncertain and 
founded only on conjectuie, was still further opposed by 
another question, in which the reasons pro and con were 
decisive. 

6. Whether, and how far, despite the testimony of the 
coachman, sliU the ladies may have lived, when he believed 
that they were already dead? 

a. When then on the side of the maternal relatives in the 
present case, it was maintained (a) that the mother, of a grave 
disposition, on account of her age, and ever had been so, con- 
sequently at the time was well, hence in so sudden a neces- 
sity, had more fletermination and energy than the three young 
ladies, and could help herself for a longer time, as also the 



Presumption of Survivorship. 



445 



testimony of the coachman conforms hereto, and strengthens 
it the more, {h) also that we do not find, as with the bodies 
drawn out from tiie water any signs of life remaining was 
discovered, (c) as also such extraction or drawing forth of 
bodies of any kind, would have occasioned irritation and mo- 
tion, if, indeed, with one or the other, any had been left: {d) 
in addition, the delicate young ladies by excitement would 
have been brought rather to cramps in the breast and convul- 
sions, and hence death would be hastened, so that the mother 
survived them, (e) consequently the lying down and want of 
motion in tlie young ladies, which the coachman testified to 
as the signs of death, are also on this account the more suffi- 
cient to prove their death, and hence to confirm the testimony 
of the coachman and the perfect death of the daughters be- 
fore the mother, therefore the maternal relatives are entitled 
to maintain the inheritance of the daughters descended to the 
mother who died last, to the exclusion of the relatives of the 
father. 

b. On the other hand the relatives of the father contended 
that (a) the vital power at the age of the three ladies was 
generally able longer to withstand death, than at the age of 
the mother, as the latter had been affected with hemorrhage 
and other ailments, and {b) that after the bodies were drawn 
out, no bleeding, warming or rubbing, &c., was made use of, 
as these attempts might be useful to restore life or as a possi- 
ble proof of the death, as (c) the motion of the bodies at the 
time of the drawing them out from the water and the coach, 
is in no manner to be compared with the carrying of them, 
and {d) farther syncope and cramps in the breast in which the 
three ladies had earlier fallen, so much the less proves death, 
as it is well known, that, particularly with females, in the 
h'ke cases, besides that they grow faint and numb, frequently 
the pulse cannot be felt in the external arteries, as also respi- 
ration without a movement of the breast, and only by a slight 
motion of the diaphragm be discovered, and yet such per- 
sons recover, hence (c) we particularly cannot know, whether 
and how long the young still had life, they might have swam 
away, and the stieam have carried them on more alive than 
absolutely dead: besides also the lying down and immovable- 
ness of the three ladies, which the coaclmian testifies to, still 
less, than the outcry of the mother, as they were found in the 
■water, can prove the absolute death of all these persons; the 
rather (/) that these and many more signs may deceive, 
although {g) people, who have been a considerable time under 
the water, indeed olten recover, if application is made use of; 



446 



Presumption of Survivorship. 



as the young ladies were three in number, and on the 3d of 
September, the water was not so very cold, it is the more 
evident, tliat when they were brouglit to the bank, if not all 
three, together witli the mother, yet one had a spark of life 
and might have been saved. For these and other reasons, 
together with the presumption of law, we consider that the 
testimony of the coachman deserves no credit. 

Fourthly. When many persons are precipitated into an 
abyss and dashed to pieces. 

In this case we must particularly examine, on whom 
wounds of the nobler organs are found. Thus, for example, 
those will die earlier whose skull is fractured, than those who 
have suffered the fracture of an arm or leg. Those also will 
have died the earliest, on whose corpses we find the internal 
vessels lacerated, than those who have received a flesh (bleed- 
ing) wound on the extremities. But where many persons in 
the same manner', and by the same injury are killed, he will 
have died the earliest on whom the injury first happened, or 
also that one on whom the severest lacerations are found. 
But where the wound is equally great on many persons, or 
has happened to all on one and the same organ, then the 
stronger will have survived the weaker. The idiosnycrasy of 
the person may, however, in the last case, afford a ground of 
distinction, as when, for example, death is caused by extrava- 
sation of blood in the skull, a full-blooded person or one who 
has a tendency to apoplexia sanguinea, will die sooner than 
those with vvliom this is not the case. 

Fifthly. When many persons perish at the same time in a 
conflagration. 

In such a case we must first ascertain, whether the persons 
are really burnt, or suffocated by smoke, or entombed and 
crushed by the falling buiklings. 

The distinctive signs of persons dead from suffocation and 
wounds have already been mentioned. 

In respect to death by burning we must decide, whether 
the man was really burned alive, or whether we find signs 
upon the dead body, that the marks of burning have been 
occasioned after death, resulting from some other cause. On 
this point we have a very interesting essay by Christison. 

A case of many persons destroyed by fire, which on account 
of the claims set up to the inheritance occasioned judicial 
proceedings, is to be found in Kopp's Jahrbuch der Staatsarz- 
neikunde, 71, 8, p. 181. At Ormay, in the district of Murten 
in the Canton of Fryburgh, a fire in the night of the 16th 
and 17th of June, 1809, broke out in the dwelling of a coun- 



Presumption of Survivorship. 



447 



tryman, Jean Etter. The man was absent, and expected to 
return the same evening, his wife on that account had re- 
mained, according to her custom, waiting for him in the room, 
where she was found alone with her infant. The other four 
children slept in a little adjoining chamber. All the five chil- 
dren together with their mother perished in the fire. 

It was impossible to discover in what part of the house the 
fire originated. The body of the mother was found nearly 
destroyed by the flames. Her infant, with its body almost 
uninjured, lay under her. A few steps further lay the oldest 
daughter, 14 years of age. The three other children were 
found together in the centre of the hall. 

There was no marriage contract, and the father remained 
for a while in the quiet possession of the inheritance of his 
wife, who had brought to him on the marriage a considerable 
real estate from her paternal and maternal side, as also some 
stocks and money. 

The provincial law in force there permitted to the surviving 
husband, the usufruct for life in the property of the wife; but, 
when he claimed the inheritance, he must present an inven- 
tory and give security. According to the laws the property 
of intestates belonged to the nearest blood relations, who have 
survived the deceased. 

When Etter was about re-marrying, the sister of the de- 
ceased claimed, that he should fulfil the requirements of the 
law, but he refused and the court decided, that the inherit- 
ance should be divided: but with this the sister was not con- 
tent, and her advocate appealed from the provincial law, 
since, because it was not proved, whether the mother or her 
children had survived, it must be assumed according to the 
Roman law and the code Napoleon that the mother was the 
survivor, and consequently that the sister was the heir of the 
deceased. 

On the other hand, the counsel for Etter contended, on the 
same authorities, that it was not sufficient, that Marie KnoflT 
for the establishment of her claim, should represent herself as 
the nearest relative of the deceased, but it rested solely on 
this, whetiier she at tlie time of the death was her next blood- 
relation, which could not be the case, if only one of the five 
children had died after the mother. He attempted to prove, 
how extremely improbable it was, that the mother had sur- 
vived all the five children, and produced the following strik- 
ing circumstances. 

1. The children, who perished with their mother, were five, 
and their bodies were found in different parts, of the room; 



448 



Presumption of Survivorship. 



they could not thus all at the same time, in the same moment 
have lost their lives, as was before assumed, if for example, 
they had all been entombed under the ruins. Also in refer- 
ence to their different positions it is almost a certainty, that 
one or another of the children had lived longer than the rest, 
and it is the extremest improbability, that all five of the chil- 
dren should have died before the mother, and not even one, 
were it only for a second, had survived her. As to the sur- 
vivorship of one of the children we may place five against 
one. 

2. The body of the mother was so much destroyed by the 
flames, that it excited horror, while that of the child, which 
she had under her. was scarcely injured. The unhappy mo- 
ther had used her best endeavors to protect her child, and 
forgot on that account her own danger. Without doubt she 
covered it with her body and her dress, it was thus covered 
from the flames and less exposed to the effect of the smoke, 
while the mother was entirely exposed to them. We have 
thus reason to assume the survivorship of the child, in respect 
to the temporary {momentanen) protection derived from the 
mother. 

3. The oldest daughter, about 14 years of age, was found a 
few steps from her mother, her body was entirely uninjured, 
so that her hair and the ribbon upon it exhibited not the 
slightest trace of burning. This proves, that not the flames, 
but merely suffocation occasioned her death. We must not 
forget, that she slept in the little adjoining chamber, and that, 
when she came out, the firesmoke must have already reached 
her mother, even if the flames had not yet destroyed her. 
At least the following circumstance gives strong reason to 
conclude, that she was already dead and had perished by the 
flames and smoke, when the children left their chamber. 

4. Three of these children were found together, in the cen- 
tre of the hall. They had thus fled from the chamber, come 
through the common room, had opened that door and thus 
reached the front door. Could they have opened the front 
door, they would have been saved. Hence it is in the high- 
est degree probable, that already on their flight the mother 
was dead, ibr it is natural, that if she had been still alive, she 
would also have attempted an escape, and have aided all, to 
reach the front door. 

The decision of the superior court is unknown to the au- 
thor. 

A fire broke out at night in the year 1546 in the Castle 
Blankenburg on the Hartz, and the count and his pregnant 



Presumption of Survivorship. 



449 



wife, as well as the steward and his wife could not ecsape 
from the flames. They escaped from one chamber to another, 
until the two females were sutibcated by the smoke; the two 
men remained alive and were at length taken out from the 
flames. The countess was 37 years old, the age of the other 
persons is not given. — S. Th'ieringen unci der Harz. 81 Heft. 
page 56. Sondenhausen bet Eupel 1840. 

Sixthly. When many persons die at the same time of poi- 
soning. 

In the poisonings of many persons by one and the same 
kind of poison we consider those as dead first, on whose bo- 
dies we find the greatest destruction by the poison. 

On this point no decision can be based, since indeed the 
greater the degree of the destruction in the body presupposes 
a longer life, and there are poisonous substances which pro- 
duce no destruction in the body, and in corrosive poisons 
arsenic acts in a twofold manner, as it kills by an effect upon 
the nervous system, or occasions an inflammation of the sto- 
mach and intestines passing into gangrene, to which in the 
decision of such a case reference must be had. Even in the 
case, where a person poisons another and afterwards poisons 
himself, the knowledge of the person of the mixer of the poi- 
son is not sufficient to decide the priority of death, since if 
the poison administered was arsenic, the poisoned person, who 
first had taken the poison, still may have died last, if the poi- 
son produced its eflects more slowly upon him, while the poi- 
soner may have died earlier than the former by the more 
speedy effect of the poison. 

Death by poisoning appears to proceed in the reverse order 
of death by hunger or by bleeding; and the elder to die be- 
fore the younger. 

Persons may die at the same time apparently by poisoning, 
without this really being the case. 

Dr. Iloloff relates the case of two men who died suddenly 
and probably by poison, with whom on dissection no trace of 
poison could be proved, although the symptoms of disease, as 
also the appearance on dissection indicated a poisoning, so 
that Rolotf had to leave it undecided, whether the two young 
people had died of gastritis, enteritis, cholera or malignant 
typhus. They were two brothers, of whom the eldest was 
18 and the youngest 13 years old; the first died Feb. 3, and 
the last Feb. 21. — Kopp. Jahrhuch des Staalsarzneikunde, 7 
Jahrgang 1814. 

Seventhly. When many persons die at the same time of 
wounds. 

5 



450 Presumption of Survivorship. 



Klose lays down in this case the following principles: 
1. With duellists, who die at the same time, the degree of 
mortality decides for the earlier or later death. 2. If from an 
examination of the bodies it appears, that the one had been 
murdered by another, and the murderer had then killed him- 
self: Klose assumes, that the suicide had died last, and cites 
a recent case, where a man murdered his wife with an axe, 
but drowned himself. In this case the husband had survived 
the wife. But on the other hand, had the man thrown the 
wife in the water and she had died of suiTocation, while he 
had shot himself, the wife may very easily have survived the 
husband. 

3. When in cases of wounds of the same kind the wound- 
ed organs of a person are morbid or weak, we may assume, 
that the persons, who are of the weaker organisation, have 
xiied first. 

4. If a cannon ball strikes several persons we may assume, 
that those have died first, who were struck first. 

In the siege of Breslau, a soldier was struck by a cannon- 
ball on the shoulders and was killed on the spot; the same ball 
crushed the head of another soldier standing several hundred 
feet distant. — Klose, System, p. 395. 

With persons of different sexes, but with wounds of the 
same nature, Klose assumes, that the female will have died 
earlier than the male. But it is suflicienlly known, that 
bleeding with women is less dangerous and less speedily pre- 
judicial, and we must therefore assume that the man in such 
a case has died earlier than the woman. Besides, nature sti- 
fles in woman bleeding sooner than with men, since the for- 
mer are inclined to fainting, which is the best means of stop- 
ping bleeding. — Klose, iiber der Eivjluss c/es Geschlechtsunters- 
childs, p. '246. 

Eighthly. When many persons die at the same time by 
cold. 

Bernt, Henke and Mendel assume apoplexia cerebralis as 
the only cause of death from cold; but Niemand {Handb. der 
Staatsarzneikunde, p. 210,) and Granland {Dissertat. de As- 
phyxia congelatorum, Helsingforsia3 IS32) place the cause of 
death in asphyxia. Metzger assumes apoplexy as the cause 
of death; but says that co'ld with a low but uninterrupted de- 
gree of coldness, occasions death by its fatal efiects upon the 
nervous system and the heat of the body; death by cold may 
be thus sudden or protracted. With these opinions the re- 
sults of dissection of those who have died from cold coincide. 
In general, we find in these cases the skin uncommonly pale, 



Presumption of Survivorship. 



451 



the vessels of the head empty, the intestines very full of blood, 
and the lungs near the pleura inflamed. Klose, 1. c. p. 429. 
Cappel (-4.c<a xYrt/«?-. C?/rfosor(//«, vol. 3, obs. 2S,) found con- 
gestion in the breast and the abdomen, and Plouquet {von 
getcalsamen Tod>:sarten) found the vessels of the head and the 
lungs filled with blood. 

The prevalent circumstances, whether a person was stron- 
ger, fatter, better clothed than another, whether one had a 
tendency to apoplexy or fainting or had drunk ardent spirits, 
must in reference to the appearances on dissection afford an 
evidence as to the earlier or later death of the one person or 
the other. Children and old people are killed by cold, more 
easily than persons in middle age: but women, who are in the 
climacteric years, are killed by cold under the same circum- 
stances not so easily as men, because they possess proportion- 
allv a warmer blood and more animal heat (warmth of 
body). 

Ninthly. When many persons perish at the same time of 
hunger. 

When persons die from hunger at the same time, the place, 
where it has happened, must first be considered. Thus, death 
follows later with those who are found in a damp place, a eel- 
lar, &c., where they can breathe a moist air or can drink. la 
reference to sex, women can endure hunger longer than men, 
who require a greater quantity of more nourishing and stimu- 
lating food. Further, weak persons will perish from hunger 
sooner than stronger ones, younger persons than older ones. 
Young active men will be destroyed by hunger sooner and 
more severely, than phlegmatic, quiet, less respirable, old per- 
sons, who require less food, than younger ones. 

The truth of this position is proved by the melancholy 
end of Count Ugolino in Pisa, whom the citizens together 
with his family, closed up and starved in the year 1283, in 
the Hunger-castle so called. The youngest child, a boy of 3 
years old, died first on the fourth day, the three others in 
youth, the fifth and sixth day, the father in the prime of life, 
died the eighth day. Dominicus Sala, Tractat. de alimentis, 
sect. 1, p. 32. In Oppido, a maiden lived eleven days under 
the ruins, and in the most horrible proximity to a corpse. 
She was 15 years old, and the attendant of a child. On the 
falling of the house, she held the child firmly in her arms, 
who, tormented by the most torturing thirst, died on the fifth 
day. Till then she had preserved her presence of mind, but 
afterwards she experienced the most painful sensations of 
hunger and thirst. Her despair passed into perfect senseless- 



452 Treatment of Uterine Hoemorrhages. 



ness, and at the time she felt nothing of the pain of the dis- 
location of her hip, on the falling of the house. Drink was 
the only thing which she desired after her deliverance. When 
asked respecting her condition under the ruins, she answered: 
/ slept. Many of those entombed persons were found on be- 
ing dug out in a stupor-like sleep, in which they had sunk l)y 
the falling or after some days, according as their nervous sys- 
tem was strong or weak; many considered themselves as in- 
toxicated. 

An old woman lay seven days under the ruins in a state 
resembling sleep; when she awoke, her only complaint was 
of burning thirst. — Amer. Journ. Med. Scien., from Wild- 
berg's Jakrbuch der Gesmnmten Slaatsarzneikunde. 



A tabular view of the treatment of Uterine Hemorrhages. — 
By William Camps, M. D., Edin. 

n.53M0RRIIA.GE BEFORE PARTURITION. 

A. Slight Hcemorrhage. — Horizontal position; perfect re- 
pose; cool air; cool acidulous fluids; low diet; bleeding, if 
there be symptoms of plethora. The bladder and rectum to 
be emptied. 

B. Severe Hcemorrhage. — The same treatment as in A., ex- 
cept the bleeding (1). At first, cold applications; then the 
ergot of rye, in doses of 12 grains, repeated three times, at 
intervals of ten minutes. And if these means are insufficient 
to arrest the haemorrhage, plug the vagina, or in some espe- 
cial cases rupture the membranes (2). 

HEMORRHAGE DURING PARTURITION. 

Slight HcBmorrhage. 

Os uteri not dilated, and not dilatable. 

Membranes entire: — The same means as in A., except 
the bleeding, which is not indicated unless the symp- 
toms of plethora are exceedingly pronounced. 

Membranes ruptured: — As above. 
Os uteri dilated. 

Membranes entire: — The same means as in A.; then 
wait, or rupture the membranes (3). 

Membranes ruptured; — The same means as in A., and 



Treatment of Uterine Hcemorrhages. 



453 



wait; if the pains are feeble or slow, give the ergot 
of rye (4). 

Severe Hcemorrhage. ' 
Os uteri not dilated, and not dilatable. 

Menibranes entire: — The same treatment as in A., ex- 
cept the bleeding; then the refrigerants, as cold ap- 
plications. Jn case these fail, and if the pains are 
feeble, the ergot of rye; then rupture the mem- 
branes. Lastly, if the state of the os uteri will not 
allow of turning, plug the vagina. 

Membranes ruptured: — The same treatment as in A.; 
refrigerants; ergot of rye if the pains be slow or 
feeble. In case these fail, compression of the uterus; 
plug the vagina; introduce the hand, and deliver by 
turning (5). 

Os uteri dilated, or dilatable. 

Membranes entire: — Rupture the membranes (6); and 
if this does not succeed, introduce the hand and 
turn, or apply the forceps. 

Membranes ruptured: — Turning, if the head of the 
child has not descended into the cavity of the pel- 
vis (7). Apply the forceps if the head of the child 
have already descended into tjie cavity of the pelvis. 
Simple extraction if the chTld present by breech, 
knees, or feet. 

(1) . The ergot of rye is employed here as haemostatic; in 
the case supposed, there is not, at present, uterine pains; it is 
not probable that the employment of the ergot of rye should 
produce them, for hitherto this remedy appears to possess the 
property of increasing the uterine contractions only when 
they occur spontaneously, and not that of exciting them, 
when they do not already exist. 

(2) . The plug will, in the first place, arrest the hemorrhage; 
then, by the retention of the blood, and by its presence, it 
will irritate the neck and orifice of the uterus, and it will in- 
duce the expulsive contractions. These will dilate the os utei'i, 
and this dilatation will allow either the rupture of the mem- 
branes, or the termination of the accouchment. 

(3) . This rupture can have no inconvenience; it is a means 
of preventing the increase of the haemorrhage. We may 
always dispense with it, and rest satisfied with waiting until 
the progress of the labor shall have arrested the haemorrhage: 



454 Treatment of Uterine Hcemorrhages. 



the last method is after all perhaps the most prudent. A lit- 
tle more or a little less tendency to the increase of the hsemor- 
rhage should determine the choice of the one or of the other 
method. 

1st. Wait, if the ha;morrhage do not increase in any de- 
gree, and still more so if it diminish. 

2d. Rupture the membranes if there be any tendency to in- 
crease of the haemorrhage; this rupture will be profitably 
preceded or followed by the administration of some doses of 
the ergot of rye, if the uterine pains are feeble or slow. 

(4) . It may be asked, if it would not be proper to termin- 
ate the accouchement in this case, since the parts concerned 
seem disposed to this termination. We think that if the foe- 
tus presents in the usual manner, it is better not to be offi- 
cious with the application of the forceps or turning, because 
the employment of these means would be more severe than 
the slight haemorrhage which appears to demand their use. 

(5) . This case is one of great delicacy; the application of 
the plug here requires great caution; for when the vagina is 
closed up, the blood may possibly accumulate in the cavity of 
the uterus, so that the patient may be lost, although no blood 
make its appearance externally; and the danger will be so 
much the greater, as the uterus shall have been mor^ devel- 
oped before the rupture of the membranes, and as the uterine 
contractions shall be more feeble. The application of the 
plug should be pi eferred, to the termination of the accouche- 
ment, only when the uterine contractions are sufficiently 
strong, and when, at the rupture of the membranes, only a 
very small quantity of the liquor amnii shall escape from the 
uterus. Again, the application of the plug demands great 
care of and attention to the patient, and should be followed 
by the application of a bandage round the abdomen sufficiently 
tight to resist the enlargement of the uterus. On the con- 
trary, when the uterine contractions are feeble, when a large 
quantity of the liquor amnii shall have escaped at the moment 
of the rupture of the membranes, it will be necessary to over- 
come the resistance offered by the state of the os uteri, and 
terminate the accouchment by turning. 

(6) , In this case we may be surprised at the advice to rup- 
ture the membranes, and loait, before adopting any other 
method, according as the retraction of the uterus may have, 
or may not have, arrested the haemorrhage; it seems so im- 
portant, both to the mother and to the infant, that the birth 
of the latter should be the result of the uterine contractions 
alone, rather than of manual interference, very often difficult. 



Treatment of Uterine Hcemorrhages. Abb 



that it is very desirable to take the chance of a spontaneous 
accouchment at all times when there is the probability of ob- 
taining it. It is to be understood that this recommendation 
to wait, is only admissible in case the uterine contractions are 
neither feeble nor slow. 

(7). We may certainly in this case have recourse to the 
forceps, but the employment of this instrument, when the 
head of the child is above the orifice, and not engaged in the 
cavity of the pelvis, frequently ofiers sufficient difficulty to 
render the delivery by turning preferable. 

It will be seen that the indications are based on the slight- 
ness or severity of the haemorrhage, and not on the circum- 
stance of the insertion or non-insertion of the placenta on the 
neck of the uterus; not that this circumstance is a matter of 
indifference, for almost always the haemorrhage produced by 
the detachment of the placenta inserted over the orifice of the 
uterus, is one of a severe and serious chaiacter, and demands 
immediately the employment of the means indicated for 
severe haemorrhages. Sometimes the insertion of the pla- 
centa on the neck of the uterus occasions only a slight htem- 
orrhage: the author does not consider, then, as do the greater 
part of accoucheurs, that the insertion of the placenta on the 
neck of the uterus requires, in every case, the speedy termin- 
ation of the accouchment, yet it may modify the employment 
of the means above indicated. For instance, if in a case of 
severe haemorrhage the placenta covers entirely the os uteri, 
■we cannot have recourse to the simple rupture of the mem- 
branes, as we could if such were not ihe case. If the os uteri 
be neither sufficiently dilated, or sufficiently dilatable, Xo allow 
the introduction of the hand, it will be necessary to employ 
the plug; if, on the contrary, it be sufficiently dilated, or suffi- 
ciently dilatable, it will be necessary to detach one of the 
sides of the placenta, in order to make a passage into the 
cavity of the uterus, and deliver by turning; but if a portion 
only of the placenta be inserted on the os uteri, leaving ex- 
posed a part of the membranes, we may proceed as if the 
placenta were not inserted at the os uteri. In no case does it 
seem advisable to make a passage through the placenta, as 
some accoucheurs have recommended. Lastly, if the pla- 
centa, pushed by the head or the breech of the foetus, be 
entirely, or almost entirely detached, and has passed beyond 
the orifice of the uterus, we must extract it before the foetus, 
for this organ is useless in these circumstances, and its pre- 
sence in the vagina is an obstacle to tiie free exercise of the 
hand, or of instruments. — Med. Ex. and Retros. of the Med. 
Sci., from Land. Med. Gaz. Jan. 13, 1843. 



456 • Syphilitic Buboes. —Treatment of Goitre. 



On Primanj Syphilitic Buboes. By De Castlenau. — May 
a bubo of a truly syphilitic nature arise without antecedent 
chancre? Many writers on syphilis say yes. Many with one 
of the latest and ablest, Ricord, say no. De Castlenau has 
given the details of three cases, in which there seems to be 
no reason to doubt of the origin of the buboes, independently 
of antecedent external chancre. In one of these cases there 
was the very decisive evidence of the specific nature of the 
sore which followed the opening of the bubo, in the acciden- 
tal inoculation of the surface in its neighborhood. 

Pell (Marg.), aged 20, a week after connection, was seized 
with the ordinary symptoms of gonorrhoea, and by and by 
perceived a swelling in her right groin. The parts were ex- 
amined with great care; no excoriation or ulceration was dis- 
covered either externally or internally; neither were there now 
any symptoms of gonorrhoea present. In the right groin there 
was a bubo, superficial, and on the point of giving way; in 
fact it did give way immediately after the visit. Next day 
another examination was made, but no chancre was discov- 
ered. The open bubo exhibited hard, inflamed, and sharply 
defined edges; the surface was gray and chancre-like, and 
suppurating copiously. Above the open sore a small pustule 
was observed, apparently the consequence of the natural in- 
oculation of the pus poured out by the bubo. The wound 
was cauterized with nitrate of silver in substance. Two days 
later the sore had still the same chancrous character. The 
pustule was now a regularly rounded sore, with raised edges, 
sharply cut, and rather hard and red; its bottom was gray. 
A second pustule, like the first, was perceived on the skin to 
the inside of the principal sore. Three days afterwards this 
second pustule had become a chancrous sore, with the same 
characters as the other two. The patient, under appropriate 
treatment, recovered. — Lond. and Edin. Med. Journ. Med. 
Sci. Feb, 1843, from Archiv. G6n. de Mid., Dec. 1842. 



On the Causes and Treatment of Goitre. — A communi- 
cation was read to the French Academy of Sciences, August 
1, from Pascal, on the local influences which assist in the 
development of goitre, and on the use of ferruginous mineral 
waters in preventing and curing tliis affection. From the 
observations of Bcnrdict, Foderc, and Roulin, it appears, 1st, 
That the stagnation of humid air, whether cold or warm, emi- 
nently predisposes to this disease, and that all the moist gor- 



Convex Spectacles in Asthenic Amaurosis. 457 



ges of the mountains towards the north are more particularly 
the localities in win'ch bronchocele exists to the greatest ex- 
tent. 2cl. That the use of impure cold water, as the habitual 
beverage, is, if we may say so, the exciting cause of the 
afiection in those places already predisposed. The water 
from wells, cisterns, and pumps, is said to be the most injuri- 
ous. 

Pascal then directed attention to the following fact: — At 
about three leagues from Metz are th.ee villages, named 
Pierre Villers, Rombas, and Villers les Rombas, all of which 
are similarly situated as regards hygiene, with the exception 
that Villers had a chalybeate spring, which was generally 
used by the inhabitants for cooking and drinking. Now fifty 
years ago, while goitre attained a large size, and was very 
common in the two other villages, it was unknown in Villers; 
and it was observed, that those who came to reside in it from 
Pierre Villers and Rombas, got cured if they were already 
affected with the disease, or if they had it not at the com- 
mencement of their residence, continued free from it. From 
this circumstance we cannot but admit that the chalybeate 
was the cause of the inhabitants of Villers not being atiected 
with bronchocele. Since the above period goitre has almost 
entirely disappeared from the other two localities, owing to 
the improvements that have taken place in the condition of 
the atmosphere, in the houses of the villages, and in the food 
of the inhabitants. 

From these facts we may conclude, 1st, That notwithstand- 
ing the humidity and stagnation of the atmosphere, the use 
of a chalybeate water prevents the development of goitre, 
and cures it when it is formed; and, 2d, That even when no 
ferruginous spring exists, amelioration in hygii*ne greatly 
counteracts the predisposition of the inhabitants to be affected 
with bronchocele. — Ainer. Journ. Med. Scien., from Land, 
and Edin. Month. Journ. of Med. Sci., Dec. 1842. 



Asthenic Amaurosis cured btj the use of convex Spectacles. — 
Taking a hint from certain quack vendors of spectacles. Dr. 
CuNiER, of Brussels, has made trial of the effects of convex 
glasses, in what he terms cases of simple ancesthesia of the i-etina, 
and with a considerable share of success. The influence of 
the ilight, directed upon the retina by such glasses, appears 
beneficially to excite the sunken sensibility of the optic nerve. 

A lady, whose case he relates, could not for eight years 



458 



Slruciwe of the Arteries. 



without difficulty distinguish with her left eye the large char- 
acters forming the title of a newspaper; could not tell the 
hour on the clock, unless her eye was within two inches of 
the hands, nor distinguish the feature nor the figure of a per- 
son at the distance of two feet. If the right eye was covered, 
the left pupil became dilated, and remained so. 

Glasses, whether concave or convex, ought always to be 
distinguished by their focal lengths, and not by numbers. As 
Dr. Cunier employs the latter mode, we are at a loss to know 
the precise power of No. 3, with which the patient could read 
a large type with her left eye, but probably it was a convex 
lens of three inches focus. After exercising the eye with 
this lens for some minutes, vision became confused and the 
head painful, so that the patient was obliged to desist. Next 
day she could with No. 82, and on the third day with No. 4. 
The duration of this kind of exercise was gradually length- 
ened, and glasses of longer and longer focus employed. By 
the tenth day, the patient read the hour on the clock at the 
distance of 22 inches, and recognised individuals at double 
that distance. By the seventeenth day of the treatment. No. 
24 was employed, and ihe patient could read small type. After 
two months use of No, 24, the sight of the left eye was as 
good as that of the right. 

Several other successful cases are related by Dr. Cunier. — 
B. and F. Med. Rev., from Annales d'Oculistic/ue, May. 
1842. 



Structure of the Arteries. — After a variety of conflicting 
and unsatisfactory accounts, Henle seems at length to have 
discerned such structures in the arteries as are adapted to the 
functions which experiment shows to be performed by them. 
His account of the general structure is briefly this: 

1st, They have an epithelial lining, consisting of a very 
thin layer" of elliptic or rhombic lameller cells, which are 
sometimes elongated into longitudinal spindle-shaped fibres.* 

2d, There is, immediately external to this, a layer of pecu- 
liar tissue, the striated or fenestrated coat (corresponding to 



• Reraak and Reichert (MiiUer, Arcliiv. 1841, clxxxviii), hold, that these are 
not the innermost cells of the vessels, but that within these, and in actual contact 
with the blood, there is a layer of flattened, round, and polyhedral cells, with 
round, yellowish nuclei and nucleoli. On all these observations by Henle, see 
Reichert's remarks. 



Structure of the Arteries. 



459 



the internal co